This document discusses chronic specific bone infections, focusing on tuberculosis, brucellosis, fungal infections, and syphilis. It provides details on the epidemiology, pathology, clinical presentation, investigations, and management of tuberculosis of bones and joints. Key points include that tuberculosis can spread to bones and joints hematogenously, leading to inflammation, necrosis, and caseation. Joint symptoms include pain, swelling, and stiffness. Diagnosis involves imaging, tuberculin skin tests, and culture of synovial fluid or biopsy. Management typically involves rest and long-term antibiotic therapy, with surgery sometimes needed to drain abscesses or decompress the spinal cord.

1. CHRONIC SPECIFIC
BONE INFECTION

2. CHRONIC SPECIFIC
BONE INFECTION
■ TUBERCULOSIS
■ BRUCELLOSIS
■ FUNGAL
■ SYPHILIS

3. TUBERCULOSIS
■ FIRST DISCOVERED BY THE FRENCH
PHYSICIAN LAENNEC (1781-1826),
WHO DIED AT THE AGE OF 45 BY TB

4. TUBERCULOSIS
■ ESTIMATED 30 MILLION TB PATIENTS
WORLD WIDE.
1 -3 % (300 000 – 1000 000)
HAVE SKELETAL INVOLVEMENT

5. Sponsored
Medical Lecture Notes – All Subjects
USMLE Exam (America) – Practice

6. Predisposing factors
■ Chronic debilitating disorders,
■ Drug abuse,
■ Prolonged corticosteroid
medication,
■ AIDS and other disorders resulting
in reduced defense mechanisms.

7. TB - Epidemiology
■ Rising prevalence nationally and
locally
■ Traditionally mostly pulmonary TB
• 60%
•40% extra-pulmonary TB (EPTB)
■ Increasing proportion of EPTB
(50%)
■ 10% of EPTB are joint TB

8. Coventry TB rate by year 1999-2006
Rate per 100,000 population
0
5
10
15
20
25
30
35
1999 2000 2001 2002 2003 2004 2005 2006
rate
Coventry
PCTWest
MidlandsEngland &
WalesLinear (Coventry
PCT)
Covent
ry
2007

9. CHRONIC SPECIFIC
BONE INFECTION

10. TUBERCULOSIS OF
BONES AND JOINTS
■ TB Bacilli lived in symbiosis with
mankind since time immemorial.
Recorded in ancient Egyptian
mummies
■ Still common in developing countries

12. REDUCED INCIDENCE
OF TB DUE TO:
■ IMPROVED LIVING STANDARDS;
SANITATION, HYGIENE, NUTRITION
■ B.C.G. VACCINE (80% PROTECTION)

13. TUBERCULOSIS BACILLI
MYCOBACTERIUM TUBERCULOSIS
BOVINE
UNPASTEURISED MILK
HUMAN
MORE COMMON
OTHERS
LESS COMMON

14. TUBERCULOSIS
GROUPS AT
RISK
NON AFFLUENT COUNTRIES
OVER GROWING MALNUTRITION,
POOR
AFFLUENT COUNTRIES
IMMUNE DEFICIENT
STEROIDS ANTICA
YOUNGER AGE OLDER AGE

16. TUBERCULOSIS
FACTORS FAVORING LOCALISATION
■ BLOOD SUPPLY AND STAGNATION
■ LOCAL TRAUMA; HAEMATOMA?
■ LOCAL STEROIDS ?

17. TB PATHOLOGY
■ Secondary to other primary TB lesions
(Pulm., Renal, Limphatic Nodes)
■ Route of spread:
HAEMATOGENOUS ****
DIRECT (much less)
* bone to joint
* soft tissue to bone
■ THE PRIMARY LESION
QUIESCENT
ACTIVE: (Apparent, Latent)

18. TB PATHOLOGY
■ INFLAMMATION HYPEREMIA - OSTEOPENIA
■ TB FOLLICLES (TUBERCLE):
LYPHOCYTE – MONOCYTES
ENDOTHELIAL CELLS
LANGHANS GIANT CELLS
Necrotic lesions
■ CASEATION
■ GRANULATION TISSUE
■ BONE DISTRUCTION
■ SINUSES

19. ■ The characteristic microscopic
lesion is the tuberculous
granuloma – a collection of
epithelioid and multinucleated giant
cells surrounding an area of necrosis,
with round cells ( mainly
lymphocytes ) around the periphery.

20. TB granuloma

21. TB PATHOLOGY (JOINTS)
■ SYNOVIAL SWELLING
FORMED GRANULATION TISSUE
■ PERIPHERAL ARTICULAR DESTRUCTION
NO PROTEOLYTIC ENZYMES
CENTRAL ARTICULAR WEIGHT-
BEARING AREA PRESERVED
■ RICE BODIES
FIBRIN & ARTICULAR CARTILAGE
■ INCREASED BLOOD SUPPLY -
OSTEOPENIA

23. CLINICAL PICTURE
■ AGE
■ INSIDIOUS ONSET
■ MONO ARTICULAR
■ OTHER LESIONS
■ FAMILY HISTORY – CONTACT
■ GROUPS AT RISK
The homeless, alcoholics,
drug addicts, prisoners

24. Joint TB - Investigations
■ Plain x-rays often normal
■ MRI can be helpful in diagnosis1
• But there needs to be a high index of
suspicion to request this
■ Aspiration of synovial fluid for TB culture
■ Synovial biopsy
• i.e. tissue for TB culture should sent in
saline or water
• Higher yield 2

25. Tuberculin-positive skin test

26. SYMPTOMS & SIGNS
CONSTITUTIONAL
■ LOW GRADE FEVER
■ ANOREXIA
■ WEIGHT LOSS
■ NIGHT SWEATING
■ TACHYCARDIA
■ ANEMIA

27. SYMPTOMS & SIGNS
LOCAL
Symptoms :
■ PAIN
■ NIGHT CRIES
■ SWELLING
■ STIFFNESS
■ ULTERED
FUNCTION
Signs :
■ SYNOVIAL SWELLING
■ TENDERNESS
■ WARM
■ STIFFNESS
■ LIMPING

28. INVESTIGATIONS
■ LEUCOPENIA – LYMPHOCYTOSIS
■ ANEMIA
■ MANTOUX POSITIVE
NOT IN:
MILIARY TB / RECENTLY VACCINATED/
ON STEROIDS / REDUCED IMMUNITY / FEVER

29. RADIOLOGY
■ CHEST X-RAY : ALL PATIENTS
■ JOINTS: PHEMISTER’S TRIAD:
1. PERIARTIC. OSTEOPENIA
2. REDUCED JOINT SPACE
3. PERIPH. OSSEOUS EROSIONS
BONES: 1. DESTRUCTION
2. SEQUESTRATION
3. ABSCESS FORMATION

30. TB hip TB spine

37. cyst

42. TB SPINE (POTT’S DISEASE)
PERCIVAL POTT 1779
■ SECONDARY TO OTHER PRIMARY
■ HEMATOLOGICAL
20% OTHER VISCERA
12% OTHER BONES/JOINTS
■ TWO ADJACENT VERTEBRAE
SOMETIMES MORE THAN ONE

43. TB spine

44. TB SPINE
SURGICAL PATHOLOGY
■ FIRST THREE DECADES
■ THORACO-LUMBAR
■ CENTRAL SPINE
SPARKS POSTERIOR ELEMENTS
SPREADEDS UP/DOWN
ANT./POST. LONG. LIGS.
■ LESIONS COALESCE – COLLAPSE
■ KYPHUS FORMATION

45. TB SPINE
SURGICAL PATHOLOGY
■ PARA VERTEBRAL ABSCESS
CERVICAL: Retropharyngeal Abscess
THORACIC : P.V. & ALONG RIBS
LUMBAR : PSOAS ABSCESS
POSTERIOR:LUMBAR TRIANGLE
ANTERIOR: ILIAC FOSSA
BELOW ING. LIG.
■ NEUROLOGICAL COMPLICATION
MORE IN THORACIC (NARROWEST CANAL)

47. TB SPINE
CLINICAL FEATURES
■ GENERAL: INSIDIOUS ONSET
CONSTITUTIONAL
■ LOCAL:PAIN – FIRST INDICATION
LOCAL – REFERRED
STIFFNESS – SPASM
WEAKNESS – NEUROLOGICAL

48. SIGNS OF TB SPINE
■ MUSCLE SPASM
■ GIBBOUS
■ TENDERNESS
■ STIFFNESS
■ PARA VERTEBRAL ABSCESS
■ NEUROLOGICAL – WEAKNESS
PARAPLEGIA

50. TB SPINE
RADIOLOGICAL FEATURES
■ DISC NOT INVOLVED PRIMARILY
■ NARROWING OF DISC SPACE
■ BONE DESTRUCTION
USUALLY TWO ADJACENT VERTEBRAE
■ MAY SHOW SKIP LESIONS
■ PARA VERTEBRAL ABSCESS
■ KHYPUS
■ CT/MYELOGRAM/MRI IN PARAPLEGIA

64. PARAPLEGIA IN
TB SPINE
■ IN 10-30% OF TB SPINE
■ MORE IN THORACIC REGION
■ PRESSURE ON CORD ANTERO
LATERAL
MOTOR EARLIER THAN
SENSORY
■ SIGNS: UPPER MOTOR NEURON
MAY START BY CORD SHOCK
■ REMARKABLE ABILITY TO RECOVER

65. MANAGEMENT OF TB SPINE
■ USUALLY
CONSERVATIVE
■ GENERAL
■ SPECIFIC
A Strict REST
IMMOBILISE
CHEMOTHERAPY
■ SURGICAL
■ DIAGNOSE
ASPIRATION
■ DRAIN ABSCESS
■ DEBRIDE
■ DECOMPRESS
ANTERIOR
ANTERO-
LATERAL
■ STABILISE FUSION

66. Treatment
Rest :
This often involved splintage of the
joint and traction to overcome muscle
spasm and prevent collapse of the
articular surfaces.
With modern chemotherapy this is
no longer mandatory; rest and
splintage are varied according to the
needs of the individual patient.

67. MOST CASES OF TB SPINE RESPOND
VERY WELL TO CONSERVATIVE
TREATMENT INCLUDING THOSE WITH
PARAPLEGIA
THE NEED FOR SURGICAL
DECOMPRESSION OF THE CORD IS
LIMITED

68. Joint TB - Management
■ Standard quadruple therapy*
■ Rifampicin
■ Isoniazid
■ Pyrazinamide
■ Ethambutol
*short course chemotherapy for spinal Tb.parthasarathy.
journal of bone and joint surgery.1999

69. How long for?

70. Joint TB - management
■ Usually 6 months is standard
■ No controlled trials for peripheral
joint TB
■ 6 months?
■ 12 months?
■ Do they require surgery?

71. Indications for surgery
■ patients aged less than 15 years, in
whom the initial angle of kyphosis is
more than 30º
■ patients started on ambulant
chemotherapy who develop
progressive kyphosis

72. Indications for surgery
■ children aged less than ten years with
destruction of vertebral bodies who have
partial or no fusion even during programme
■ patients with compression of the spinal cord
in whom the neurological status
deteriorates in spite of chemotherapy

73. Brucellosis
Brucellosis is an unusual but important cause
of subacute or chronic granulomatous infection
in bones and joints.
■ The organism :
Brucella melitensis, Brucella abortus
( from cattle ) and Brucella suis ( from pigs ).
■ Mode of infection :
Drinking unpasteurized milk or from coming
into contact with infected meat.
About 50 % of patients with chronic brucellosis
develop arthritis.

75. Pathology:
The organism enters the blood with infected
milk products or, occasionally, directly through the
skin or mucosal surfaces.
It is taken up by the lymphatics and then
carried by the blood stream to distant sites.
Focus of infection may occur in bones
(usually the vertebral bodies) or in the synovium of
the larger joints.
The characteristic lesion is a chronic
inflammatory granuloma with round - cell
infiltration and giant cells. There may be central
necrosis and caseation leading to abscess
formation and invasion of the surrounding tissues.

76. Histology

77. Clinical features:
■ Fever, headache and generalized weakness.
■ Followed by joint pains and backache.
The initial illness may be acute and
alarming; more often it begins insidiously and
progresses until the symptoms localize in a
single large joint ( usually the hip or knee ) or in
the spine. The joint becomes painful, swollen and
tender ; movements are restricted in all
directions.
If the spine is affected, there is usually local
tenderness and back movements are restricted.
The systemic illness follows a fluctuating
course, with alternating periods of fever and
apparent improvement ( hence the older term “
undulant fever “ ).

78. x-ray :
■ Loss of articular space,
■ Slowly progressive bone erosion and
periarticular osteoporosis.
■ In the spine, there may be destruction
and collapse of adjacent vertebral
bodies with obliteration of the disc.

79. Investigations:
■ Positive agglutination test ( titre
above 1/80 is diagnostic ).
■ Joint aspiration or biopsy may allow
the organism to be cultured and
identified.

80. Treatment:
Antibiotics; the infection usually
responds to a combination of
tetracycline and streptomycin for 3-4
weeks.
Alternative drugs, which are equally
effective and which may be used as
combination therapy, are rifampicin
and the newer cephalosporins.

81. SYPHILIS
■ SPIROCHETE
TREPONEMA PALLIDUM
■ CONGENITAL SYPHILIS – COMMONEST
■ CHRONIC OSTEOCHONDRITIS
PERIOSTEITIS
OSTEITIS
■ TIBIA LESABRE TIBIA

82. FUNGAL INFECTION
■ CHRONIC – VERY LOW GRADE
■ FEET – FARMERS – THORNS Madura Foot
■ SLOW DESTRUCTION
■ SINUSES – GRANULES
■ SECONDARY BACTERIAL INFECTION
■ RESISTANT TO CHEMOTHERAPY
■ NEEDS SURGICAL DEBRIDEMENT
■ IF ADVANCED MAY NEED AMPUTATION