Skeletal Tuberculosis Orthopaedics Seminar

1. ORTHOPAEDICS SEMINAR
TOPIC : SKELETAL TUBERCULOSIS
MODERATOR : DR. SARFARAZ IMAM
PRESENTED BY:
SHUBHAM CHOUDHRY , ROLL NO. 19
PRASTUTI KASHYAP , ROLL NO. 26
MANASH PRATIM CHALIHA , ROLL NO, 31
MOUSOMI MANDAL , ROLL NO. 33

2. INTRODUCTION
• Tuberculosis is a chronic infectious disease caused by
the organism Mycobacterium tuberculosis.
• TB of bone and joint is usually a secondary infection
from a primary site in the lung or genitourinary system
through hematogenous route.

3. •After lung and lymph nodes, bones and
joints is the next commonest site of
tuberculosis.
•It constitutes about 1-4% of the total
number of cases of tuberculosis.
•Most TB of bone and joint appear atleast
2 to 3 years of the onset of the primary
lesion.

4. EPIDEMIOLOGY AND PREVALENCE
•According to WHO (2010),
world – 30 million
•1/5th TB population - India.
•3% - skeletal TB.

5. •Spinal TB – the most commonest form
•Almost 50% are from paediatric age
group.
•Neurological complications are the most
crippling complications of spinal TB.

6. TB BURDEN IN WORLD
• Estimation- 1/3rd of the population
5-10% develops clinical disease during lifetime.
• Annual risks of infection in high burden countries is
estimated to be 0.5-2 %.

7. • A total of 1.6 million people died from TB in 2021
(including 187 000 people with HIV). Worldwide, TB is
the 13th leading cause of death and the second
leading infectious killer after COVID-19 (above HIV
and AIDS).
• In 2021, an estimated 10.6 million people fell ill with
tuberculosis (TB) worldwide. Six million men, 3.4
million women and 1.2 million children. TB is present
in all countries and age groups.

8. • Multidrug-resistant TB (MDR-TB) remains a public
health crisis and a health security threat. Only about 1
in 3 people with drug resistant TB accessed treatment
in 2021.
• An estimated 74 million lives were saved through TB
diagnosis and treatment between 2000 and 2021.

10. TB BURDEN IN INDIA
• According to global TB report
2021, WHO
• India accounts for about a
quarter of the global Tb
burden.
• In 2021 the estimated TB
incidence was 2590000.
• In 2021 an estimated
,population of 11,000 HIV
positive people died due to
TB and an estimated 49,300
HIV negative people died.

13. SITES OF INVOLVEMENT
• Spine(Vertebral)- Pott’s spine
• Joints- Tubercular arthritis
• Long and flat bones- Tubercular osteomyelitis
• Short bones- Tubercular dactylitis
• Tendon sheath & bursae

14. REGIONAL DISTRIBUTION
Parts of the body Prevalence(%)
Spine 42.0
Hip 8.0
Knee 7.0
Sacroiliac joint 6.0
Elbow 4.5
Tarsal bones 4.0
Ankle 4.0

15. PATHOLOGY AND PATHOGENESIS

16. PATHOPHYSIOLOGY
SPINE
LYMPH NODES
KIDNEYS
LUNGS
GIT PELVIC ORGANS
HEMATOGENOUS
DISSEMINATION
Infection reaches the
skeletal system through
vascular channels, generally
the arteries as a result of
bacillemia
or rarely in axial skeleton
through BAXTON’S PLEXUS OF
VEINS.

17. MICROSCOPIC
Tubercular bacilli vertebral Marrow macrophages Epitheloid cells
Epitheloid cells coalesce to form Langhans giant cells.
Caseation necrosis occurs due to coagulation through proteolytic enzymes.
This typical lesion is called as TUBERCLE.

18. Caseating necrosis
Epitheloid cells
Langhans giant cells
are the Three Typical Hallmark Features of Tuberculosis

19. MACROSCOPIC
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23. In patient who have competent
immunity ,disease generally starts as
Tuberculous Synovitis.
Synovial membrane :
Swollen & congested
synovial effusion
granulation tissue erodes bone
at periphery of articular cartilage,
Granulation tissue forms a Ring
(Pannus)

25. In clinical practice, it is customary to
explain,
Central Type of vertebral body
involvement,
“skipped lesions”
due to spread along Batson’s plexus of
veins
Typical paradiscal lesions and
vertebral lesions
due to spread by way of arteries.
Anterior Type
due to extension of an abscess
beneath the anterior longitudinal
ligament and the periosteum.

26. PARADISCAL CENTRAL ANTERIOR POSTERIOR

27. COLD ABSCESS
• Formed by a collection of
products of liquefaction and
reactive exudation.
• Mostly composed of serum,
leucocytes , caseous material ,
bone debris and tubercle bacilli.

28. TUBERCULAR SEQUESTRA
• Following infection marked hyperaemia and severe osteoporosis
• Lysis of bone osseous destruction compression , collapse and
deformation of bones
• Ischemic infarction of segments of bones Necrosis
• Some of the radiologically visible smaller sequestra in tuberculous cavities
(Feathery sequestra) may be the outcome of calcification of caseous matter.

29. TYPES OF DISEASES
CASEOUS EXUDATIVE TYPE
More destruction, more exudation and Abscess formation.
Onset- less insidious
Constitutional symptoms ,local inflammation, swelling – More marked
Abscess and sinus formation - occurs commonly
GRANULAR TYPE
Less destructive
Onset-insidious
Abscess formation- rare
In clinical practice, both coexist, one predominating the other.

30. FUTURE COURSE OF THE TUBERCLE
• It may resolve completely
• The disease may heal completely with residual
deformity
• The lesion may be completely walled off and caseous
tissue may be calcified
• Low grade chronic fibromatous granulating and
caseating lesion may persist with grumbling activity
• Infection may spread locally by contiguity, and
systemically by bloodstream as seen in
immunocompromised patients.

31. CLINICAL FEATURES AND
INVESTIGATIONS

32. Clinical features
• insidious in onset, monoarticular involvement
• symptoms like low grade fever and malaise,night pains, loss of
weight ,evening rise of temperature and night sweats.
• Local symptoms -pain,painful limitation of movements
• signs-muscle wasting,and regional lymph nodes enlargement.

33. INVESTIGATIONS
• X-ray of the affected part-in antero-posterior and lateral views and
x-ray of the chest are mandatory.
• In active disease -localized osteoporosis is the first radiological sign .
• The articular margins and bony cortices become hazy(giving‘’washed
out”) appearance and there is development of areas of trabecular or
bony destruction and osteolysis.
• Diminution of joint space in x-rays in area of articular cartilage

36. ROUTINE BLOOD EXAMINATION
• lymphocytosis,low haemoglobin and raised erythrocyte
sedimentation rate in the active stage of disease
MONTOUX TEST
• A positive test can be observed, one to 3 months after infection.

37. BIOPSY
• A diseased tissue is obtained from granulations, synovium,bone
,lymph nodes and examined microscopically for tubercles .
• Epitheliod cell surrounded by lymphocytes , even without central
necrosis or giant cells in a tubercle is histological evidence of
tuberculosis pathology in a patient.
• If one has decided to do a biopsy from the diseased joint and bone
,one should also obtain the enlarged lymph nodes for examination.

38. SYNOVIAL FLUID EXAMINATION
• Polymorphs leucocytosis,glucose content is reduced,protein
levels are elevated
SMEAR AND CULTURE
• Direct smear examination of pathological material such as
synovial fluid aspirate, synovial tissue, regional lymph nodes
and in osseos cavities reveal acid-fast bacilli

40. ISOTOPE SCINTIGRAPHY
• Isotopes used are technetium,gallium,indium.
• They show increased uptake in osteoporotic
fractures,infections,stress facture,healing traumatic fractures and
malignancies.
• They are sensitive but lack specificity.

41. SEROLOGICAL INVESTIGATIONS
• Serum ELISA test - detect anti-mycobacterium antibodies to
mycobacterial antigen-6,sensitivityof 94 %
• Polymerase chain reaction –sensitivity 0f 40% only

42. MODERN IMAGING TECHNIQUES
Computed Tomography scans
• demonstrate small destroyed areas in the bone and marginal
erosions .
• Swelling in the soft tissues caused by tissue
edema,granulations,exudations or abscess formation are also
demonstrated
• These changes are not specific as similar changes can be detected in
trauma,nontuberculous infections and neoplasm

43. Magnetic Reasonance Imaging
• confirm findings seen in plain x-rays and CT scan
• They show predestructive lesions like edema or inflammation of the
bone in active disease
• Encroachment of the vertebral canal,displacement of dural
sheath,localized tuberculoma,generalized granuloma can be
appreciated by MRI images

44. MANAGEMENT OF
SKELETAL TUBERCULOIS

45. PRINCIPLES OF MANAGEMENT
• Treatment of tuberculosis of bones and joints consists of
1. Control of the infection
2. Care of the diseased part.
In most cases, conservative treatment is adequate & sometimes
operative intervention is required.

46. 1. Rest in hard bed or immobilization
2.Drugs –
General policy for an average adult is to start
with “Intensive phase” treatment comprising of
daily dosage for 5 to 6 months of-
A. Isoniazid 300 to 400 mg
B. Rifampicin 450 to 600 mg
C. Ofloxacillin 400 to 600 mg
CONSERVATIVE TREATMENT

47. • The “Continuation phase” treatment should last for 7
to 8 months
. It comprises of-
• isoniazid and pyrazinamide (1500 mg per day) for 3 to
4 months, to be followed by
• The “prophylactic phase” consists of
• isoniazid and ethambutol (1200 mg) for 4 to 5
months.

49. 3.Gradual mobilization of the patient- It is encouraged
in the absence of neural deficit with the help of
suitable spinal braces as soon as the comfort at the
diseased site permits.

50. OPERATIVE PROCEDURES
1.Biopsy:-For cases where the diagnosis is in doubt, a fine needle
aspiration cytology (FNAC) may be performed from an enlarged lymph
node or from a soft tissue swelling.
2-Treatment of cold abscess:- A small stationary abscess may be left alone
as it will regress with the healing of the disease. A bigger cold abscess may
need aspiration or evacuation.

52. 3.Curettage of the lesion:- If the
lesion is in the vicinity of a joint,
infection is likely to spread to the
joint. An early curettage of the lesion
may prevent this complication.
4.Joint debridement:- In cases with
moderate joint destruction, surgical
removal of infected and necrotic
material from the joint may be
required. This helps in the early
healing of the disease, and thus
promotes recovery of the joint.
The diagrammatic drawing of curettage combined with
resection: (a) Indications: with an extensive lesion, with around
soft tissue mass, the part broken cortical bone without possibl
of reserve, with a tumor involved the articular cavity or cruciat
ligament. (b) To remove the cortical bone and soft tissue mass
without possible of reserve, and continued to dispose the
tumor cavity using curette and a high-speed burr. (c) To fill the
cavitary bone defects with allogenic particle bone graft, and
internal fixation using an anatomical bone plate

53. 5.Synovectomy:- In cases of synovial
tuberculosis, a synovectomy may be
required to promote early recovery.
6) Salvage operations:-These are
procedures performed for markedly
destroyed joints in order to salvage
whatever useful functions are possible
7) Decompression: In cases with
paraplegia secondary to spinal TB,
surgical decompression may be
necessary.

54. • OPERATIVE PROCEDURES DONE IN SPINAL TB
1) Costo-transversectomy.
2) Anterolateral decompression
3) Radical debridement and arthrodesis
(Hongkong operation)
4) Surgery for deformity correction

55. OPERATIVE PROCEDURES DONE IN TB
HIP JOINT
• EARLY STAGE Traction is given to correct
deformity and to give rest to the part.
• Active assisted movement should be
started as soon as pain subsides.
• After 4-6 months ambulation on suitable
caliper or crutches
•Advanced arthritis- The usual outcome
is gross fibrous ankylosis.
Initial traction regime
Once gross ankylosis is anticipated the limbs
should be immobilized in hip spica

56. • Arthrotomy
• Patients presenting with sound ankylosis in
bad position, upper femoral corrective
osteotomy may be necessary.
• Arthrodesis
• Arthroplasty

57. OPERATIVE PROCEDURES IN KNEE JOINT TB
• Synovectomy
to remove the focus when synovial thickening is gross
• Debridement and curettage
• Arthrodesis
Charnley’s compression arthrodesis