1) Osteoarticular tuberculosis is a chronic infection that can affect bones and joints, most commonly the spine. 2) It is caused by hematogenous spread of Mycobacterium tuberculosis from a primary pulmonary or extrapulmonary focus of infection. 3) Diagnosis requires biopsy and culture of infected tissue, as clinical features can be nonspecific. Treatment involves a prolonged course of antitubercular drugs, sometimes with surgical intervention.

1. OSTEOARTICULAR
TUBERCULOSIS
By
Dr. Amit Kumar
Assistant Professor
Orthopaedic, Apex Trauma Center
Sanjay Gandhi Post Graduate Institute of Medical Sciences
Lucknow

2. Tuberculosis is probably as old as mankind.
Its continued presence midst us is a sorry tale of
missed opportunities and mismanagement by
medical profession.
Prof. Shanmugasundaram TK
(1929–2008)
The principal investigator and project director
of the famous
Madras study of tuberculosis of the spine
(a collaborative project of ICMR, India
And
MRC, Great Britain)
(1976–1987)

3. History
TB in humans can be traced back to 9,000 years
ago in Atlit Yam, a city now under the
Mediterranean Sea, off the coast of Israel.
Archeologists found TB in the remains of a
mother and child buried together.
The earliest written mentions of TB were in India
(3,300 years ago) and China (2,300 years ago).
Skeletal Tuberculosis has been found in Egyptian
Mummy(3400 yr old)
mummy of priest of Ammon with signs of Pott's disease, tuberculosis of the spine

4. Osteoarticular Tuberculosis or Bone and joint Tuberculosis
• OA TB is 1-4% of total TB cases & 10-18% of total extra
pulmonary TB.
• OA TB appears to follow the trends of pulmonary TB and
a high incidence of resistance are being reported.
• In a series of 686 culture-positive cases of Koch’s spine
studied at a tertiary referral center, drug resistance was
noted in 111 (16%) cases with 87 (12.7%) being MDR .
Mohan, K.; Rawall, S.; Pawar, U.M.; Sadani, M.; Nagad, P.; Nene, A.; Nene, A.M. Drug
resistance patterns in111 cases of drug-resistant tuberculosis spine. Eur. Spine J. 2012, 22, 647–
652.

5. Pathogenesis
• Hematogenous spread from a primary focus such as lung,
kidney, and lymph node.
• OA TB is often a reactivation of an previous OA lesion that
has been implanted at the time of initial bacteraemia.
• Two basic types of disease patterns
 Exudative type (most often in children)
 Granular type (most often in adults)
• Spine most commonly affected, 50% of all cases of
osteoarticular tuberculosis.
• Next in order of frequency Hip, Knee, elbow, foot, hand,
shoulder, bursal sheath and others

6. Clinical features
• Chronic, slowly progressive and destructive, often resulting in walking
difficulties and disability
• Can affect any gender or age group
 Low grade fever
 Weight loss Classical constitutional symptoms may or may not
 Night sweat
 Present with pain, deformity, and the characteristic cold abscess, sinus, or a
tubercular ulcer.
 On examination, muscle wasting, localized tenderness, regional enlarged
and matted lymph nodes, and painful restricted adjacent joint movements
are commonly seen.
 A cold abscess can become subcutaneous or penetrate ligaments, bone, and
periosteum and travel along fascial planes and neurovascular bundles along
the chest wall and iliac fossa.

7. Tubercular osteomyelitis of proximal Humerus
(a) An 11-month-old boy presents with discharging sinus over right anterior axillary fold
with restricted and painful movement of his right shoulder. (b) Magnetic resonance
imaging (MRI) reveals infective lesion crossing the physeal plate of the proximal
humerus.

8. Tubercular arthritis of Knee Joint
(a) A 28-year-old man presents with pain, gradually progressive swelling in his left knee and restricted left
knee movements since the past 3 months.
(b) MRI left knee shows synovitis, bone marrow edema with erosions, osteomyelitis with para-articular
abscess, and tenosynovitis

9. • Tuberculous bacilli spread to the disc space from surrounding tissues (contiguous spread) or through the vascular supply
(hematogenous spread). Over time the disc may be completely digested (discitis), or the infection may progress to
involve the bone of each of the adjoining vertebral bodies (osteomyelitis).
• As the vertebrae degenerate and collapse, a kyphotic deformity results (Potts disease).
• Abscess / granulation tissue or Deformed vertebrae can compress spinal cord to cause neurological dysfunction.

10. Osteoarticular Tuberculosis in Children
• As disease is slow progressive & destructive, OA TB pose
alarming threat to children as they have growing physis. If
untreated or treatment delayed, can lead to functional
disability.
• Transphyseal spread (multifocal cystic bony destruction
involving the proximal metaphysis and epiphysis)can occur
in children.
• Early diagnosis and treatment is crucial to prevent serious
bone and joint destruction.
• With emergence of MDR-MBT , it is essential that adequate
samples are collected to take advantage of the available
molecular diagnostic techniques for the early detection of
drug resistances.

11. Surgeons in endemic areas tend to
“over-diagnose” TB
While surgeons in non-endemic areas
often “under-diagnose” OA TB

12. Are we diagnosing properly?
• Accurate diagnosis in osteoarticular tuberculosis poses a difficulty due to deep inaccessible
lesions, paucibacillary state, and initiation of empirical ATT in most of the cases.
Subjecting all cases to panel of investigations including
 AFB staining & culture/sensitivity,
 PCR/gene xpert
 Histopathology examination
have been proved more efficacious than resorting to single test.
• In particular serology alone is not diagnostic.
• High sensitivity and specificity of PCR and histopathology are found to be most useful diagnostic
modalities in studies.
• Tissue diagnosis: gold standard

13. Tissue for Diagnosis
• An appropriate sample must be obtained for processing when OA TB or any OA infection is
suspected.
• Cotton swab specimens from discharging sinuses should be avoided. may contain skin
contaminants
• Tissue can be obtained by
 Biopsy under image guidance (Xray /CT Guided)
 During open surgical procedures.
 Fine-needle aspiration cytology.
 Percutaneous transpedicular biopsy
 Arthroscopy

14. Radiological evaluation
• Modalities
 Xray AP/Lateral/Long Length
 MRI
 CT
 Nuclear Imaging
• Help in
 Proper Diagnosis
 Staging
 Planning surgical treatment
 Follow up

15. Approach
Multidisciplinary / Team
Physician,
 Surgeon,
Physiotherapist,
Nutritionist
Social Workers.

16. Treatment
• Aim is to control infection and care of disease part.
• Most case respond with conservative therapy few needs surgical intervention.
(MIDDLE PATH REGIME of PROF. S. M. Tuli)
• Conservative treatment:
 Rest/Bracing/ splintage
 Traction/ proper positioning of affected part
 Antitubercular drugs (4HRFlq+4HZ+4HR+4-6HE)
 Building up the patient resistance
Later- mobilization, physiotherapy & protected weight bearing.

17. Antitubercular drug
Antimicrobial therapy – Same approach as pulmonary
tuberculosis
Optimal duration of drug therapy: A topic for discussion
• Longer therapeutic courses of 18-24 months were done
for musculoskeletal TB because of concerns about poor
drug penetration into osseous and fibrous tissues.
• However, recent studies have shown that 9-12 month
regimens containing rifampin are as effective as longer
courses.
MDR TB
Medical treatment is the mainstay of therapy and it should
be based on drug susceptibility testing.
The total duration of treatment should not be <18–24
months.

18. Indication for Surgery
• To establish diagnosis
• To prevent joint destruction
• To decrease bacterial loads (remove necrotic/ infected material )
• To correct deformity
• To achieve stability
• To achieve mobility
Biopsy
Curretage of lesion
Joint debridement
Synovectomy
Osteotomy
Decompression and spinal fusion
Arthrodesis
Arthroplasty
Surgery plays an adjunctive role, done mainly in cases with inadequate response.

19. A case of a 40 year female with active tubercular spondylitis T12–L2 with thoracolumbar kyphosis.
Preoperative X-rays. (A) Lateral view (B) Anterior-posterior view. Preoperative magnetic resonance
imaging. (C) Short tau inversion recovery. (D) T1-weighted images showing active disease. Postoperative X-
rays (E) Lateral view, (F) Anterior-posterior view following pedicle screw instrumentation, posterolateral
decompression and correction of kyphosis & reconstruction with a polyether ether ketone cage.
(doi.org/10.4184/asj.2016.10.4.792)

20. Radiograph of the left hip in a 52-year-old man showing a) destruction of the femoral head and regional
osteoporosis, b) a well aligned total hip replacement three months post-operatively and c) radiograph at
follow-up of five years.doi:10.1302/0301-620X.91B10.22541)

21. A 22-year-old male presented with a 7 months history of pain and progressively increasing swelling in the left knee joint
Preoperative X-rays: AP and lateral views showing destructive knee arthritis due to tuberculosis
Postoperative X-rays AP and lateral views showing well fixed and well-positioned prosthesis (Total knee Replacement)
(Yadav S, Yadav CS, Kumar N, Kumar A. Total Knee Arthroplasty in a Case of Tuberculosis Knee in Healing Stage: Is it Safe? J Postgrad Med Edu Res 2015;49(3): 139-142.)

22. Is Osteoarticular Tuberculosis contagious: A clinical dilemma
• Although evidence of transmission (other than direct inoculation) of MTB from extrapulmonary sources is
lacking in the current literature.
• Approximately 17% of transmission occurred from persons with sputum smear-negative TB.
• The Centers for Disease Control and Prevention recommends that ‘‘persons diagnosed with extrapulmonary
TB disease should be evaluated for the presence of concurrent pulmonary TB disease’’; however, further
description of the extent of that evaluation is lacking.

23. Take Home Message
• Indolent disease, so we should have high suspicion in
patients with epidemiological risk factors & Xray showing
suggestive changes of Phemister Triad.
• Confirmed Diagnosis – Biopsy and culture of infected
material – gold standard
• Antitubercular Drugs remain the mainstay of treatment.
• Surgery is indicated in cases with inadequate response.
• Team approach is needed for comprehensive care of
patients with OA TB.