This document discusses bone and joint tuberculosis, providing details on locations, clinical features, investigations, imaging, management, and follow up. It notes that spine and hip tuberculosis are most common, and describes characteristics of tuberculosis in various bones and joints. Imaging modalities like MRI, CT, X-ray, and PET CT are outlined. Surgical indications and conservative treatment including drug therapy are summarized.

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