TB ANKLE, FOOT and ELBOW orthopaedics ppt

1. TB ANKLE , FOOT
TB ELBOW JOINT

2. •Tuberculous disease of the ankle is relatively
uncommon. The initial focus may start in the
synovium, especially in children, or as an erosion
in the distal end of tibia , malleoli and or talus.
Rarely tuberculosis of calcaneum may reach the
ankle joint after involvement of subtaloid joint
and the talus.
TUBERCULOSIS OF ANKLE

3. CLINICAL FEATURES
• Pain, limp and swelling are the earliest features.
• The swelling is evident in front of the joint and there is fullness
around the malleoli and tendo- Achilles insertion.
• The ankle joint is usually held in plantar flexion. In cases of long-
standing with gross destruction of bones and ligaments the ankle
joint may show pathological anterior dislocation.
• Radiologically during active stage marked osteoporosis is seen
with or without areas of osseous erosions or destruction in the
bones.

4. MANAGEMENT
• A painless ankylosis of the joint in neutral position (i.e.
plantigrade position) is the aim of treatment, which can be
achieved in majority of the cases by antitubercular drugs and
immobilization in a below-knee plaster cast or a suitable
orthosis.
• The patient is ambulatory with the help of crutches for first 8 to
12 weeks, thereafter guarded weight bearing is encouraged with
the plaster or orthosis on.
• The appliance is worn for 2 years to prevent recurrence of
infection and deformity.

5. • Patients who had secondary infection with gross destruction
of joint ended up with gross ankylosis or spontaneous
osseous fusion.
• Patients are usually satisfied with a painless ankle in neutral
position even if there is gross stiffness.

6. OPERATIVE TREATMENT
• Surgery is indicated for cases that are not responding to
antitubercular drugs and rest to the part, or when the
diagnosis is in doubt.
• Synovectomy with or without joint debridement is
performed for the stage of synovitis and early arthritis.
When surgery is indicated for advanced disease or for painful
ankylosis or in the presence of patho- logical
subluxation/dislocation, or in case of concomitant

7. • Secondary infection it is wise to perform arthrodesis
following the joint clearance .
• Arthrodesis should be restricted to cases with persistent
clinical disability and never solely for the radiological
evidence of joint damage.
• Rarely patient may present with ankylosis in an awkward
position, arthrodesis in neutral (plantigrade) position
should be performed with suitable wedge resection of
bones.
OPERATIVE TREATMENT

10. SURGICAL TECHNIQUE
• Exposure of Ankle joint
• Anterolateral approach is simple and can be extended distally to
expose tarsal joints if necessary. Make 8 to 10 cm long incision
lateral to the tendon of extensor digitorum centering in front of
the ankle joint. Cut sub- cutaneous tissues, extensor retinaculum
and expose the capsule of the ankle by retracting medially the
tendons in front of the joint. Avoid cutting the anterior tibial
artery and nerve situated between the tendons of extensor
digitorum

11. • laterally and tibialis anterior medially.
• Cut the capsule transversely and expose the articular surfaces
of the joint.
• Remove the diseased synovium and loose articular cartilage
and any debris within the joint cavity.
• Attempted plantar flexion, and inversion/eversion helps to
reach the deeper areas of the joint to achieve subtotal
synovectomy with or without joint debridement.

12. • . If the disease is at a stage of advanced arthritis and patients
functional demands are heavy one should proceed ahead
with arthrodesis in adults.
• For arthrodesis remove any visible articular cartilage till
bleeding raw surfaces of lower end of tibia, articular surfaces
of medial and lateral malleoli, medial, lateral and upper
surfaces of the body of talus are clearly exposed.

13. • Removal of bone should be minimum to preserve as much bone
stock as is possible. Hold the foot in the desired plantigrade
position, fill up any gaps around the site of fusion by bone
grafts, and insert Stein- mann’s pins transversally one each
through the distal part of tibia and through the body of talus.
• Close the wound over suction drai- nage and apply compression
device on the pins.
• Support the position of the limb by a strong posterior plaster
cast.

14. • Maintain the compression for 4 to 6 weeks, when the
compression device is removed and a well fitting below the knee
full plaster cast is applied.
• Now encourage the patient to walk with full weight bearing with
the plaster on.
• The plaster protection is necessary for 3 to 5 months, till solid
osseous fusion is evident on x-rays.
• If there is concomitant involvement of subtaloid joint , its fusion,
in addition to the ankle is indicated in the same sitting.
• Extend the incision distally as required, invert the foot to open
the subtaloid joint (from the lateral side) and clear away all the
diseased and destroyed tissues.

15. • Remove the articular cartilage and freshen the opposing
surfaces of talus and calcaneum, pack any gaps with bone
grafts, and insert the distal compression pin through the
calcaneum (instead of the body of talus).
• Now apply the compression clamps to exert compression
forces at the ankle as well as the talocalcaneal joint. The
remaining postoperative management is the same as for
ankle arthrodesis.
• The ideal position of fusion of ankle is recommended as
neutral flexion, slight (one to 5 degrees) valgus angulation of
the hind part of foot, and 5 to 10 degrees of external
rotation at the level of ankle.

16. • Below the knee amputation may occasionally be indicated
where destruction is severe, particularly in older patients, or if
the tarsal joints are grossly involved and deformed.

17. TUBERCULOSIS OF FOOT
• The commoner sites of involvement are calcaneum,
subtaloid, and mid- tarsal joints. Sometimes the disease may
remain limited to the central part of a tarsal bone for a long
time without extension to the neighboring joints.
• The order of decreasing frequency of such lesions is
calcaneum, talus first metatarsal, navicular, first and second
cuneiforms, cuboid and other bones.
• Endarteritis of the nutrient artery in such lesions is common
and many would show a cavity with or without a typical
coke-like sequestrum on the x-rays

18. TUBERCULOSIS OF FOOT
• Diagnosis is easily made by the presence of pain,
swelling, tenderness and cold abscess/sinuses.
• X-rays reveal osteoporosis, areas of bone
destruction and cavitation.
• Comparative X-rays of both feet may be of help.
• Low grade pyogenic infection and rare
granulomatous conditions (mycosis, brucellosis,
sarcoidosis, etc.) have to be considered in
differential diagnosis.

19. • Conservative treatment with below knee plaster cast or a below knee
orthosis with a fixed ankle combined with antitubercular drugs is as a
rule effective in a majority.
• Surgical excision of a large isolated osseous lesion (e.g. in calcaneum)
to prevent involvement of adjacent joints, or debridement and
curettage may be indicated in nonhealing lesions.
• Whenever the diagnosis is in doubt the diseased tissue should be
obtained for microbiological and histological studies by core biopsy or
by open biopsy.
TUBERCULOSIS OF FOOT

20. • If surgical treatment be indicated in a joint involvement the operation
should be combined with deliberate arthrodesis.
• If talocalcaneo-navicular joints are involved a standard triple
arthrodesis is necessary.
• If involvement is of ankle, subtaloid and midtarsal joints
concomitantly, pantalar arthrodesis is justified.
TUBERCULOSIS OF FOOT

21. • Tuberculous disease of the elbow constitutes nearly 2 to 5
percent of all cases of skeletal tuberculosis.
• The disease commonly starts from the olecranon or the
lower end of humerus, sometimes the onset is synovial or
from the upper end of radius.
• In active stage the joint is held in flexion, looks swollen, is
warm and tender.
• Swelling is maximally appreciated at the back of the elbow
on both sides of olecranon and the triceps insertion.
TUBERCULOSIS OF THE ELBOW JOINT

22. • Movements are accompanied by pain and muscle spasm.
• Marked wasting of arm and forearm muscles is obvious.
• Supratrochlear and/ or axillary lymph nodes are enlarged in nearly
one-third of the patients.
• Sinuses connected with the joint may form rarely.
• Radiologically areas of destruction can be seen commonly in the
olecranon and/or lower end of humerus.
TUBERCULOSIS OF THE ELBOW JOINT

23. TUBERCULOSIS OF THE ELBOW JOINT

24. • In addition to general treatment and systemic antitubercular drugs
the elbow is given rest in the best functional position.
• In a unilateral case 90° of flexion and midprone position of the
forearm is advisable.
• If a patient with active disease presents with the elbow in extended
or any awkward position the joint should be gradually brought to
neutral position by change of plaster at weekly intervals or by change
of position under light anesthesia.
MANAGEMENT

25. • As soon as the pain in elbow permits, active assisted repetitive flexion-
extension and pronation-supination exercises are started.
• The splint (with the elbow held in 90° and forearm in midprone position) is
worn for 6 to 9 months in between the exercises and at bed time.
• After the removal of splint one should avoid overuse of the joint for
another 9 to 12 months.
• In advanced arthritis with involvement of all compartments of elbow the
end result is usually a gross fibrous ankylosis.
• If it is an advanced disease with unacceptable ankylosis one should
proceed with excisional arthroplasty.
MANAGEMENT

26. Excisional Arthroplasty

27. • Operative fusion of the elbow (essentially ulnohumeral joint) in
tuberculous arthritis is rarely indicated where heavy manual strength is the
primary aim, majority of patients, however, prefer a resection arthroplasty
to the fused elbow.
• For unilateral disease a position of 90° flexion is desirable.
• For bilateral cases, one elbow should be placed at 110° flexion to reach the
mouth and face and the other at 65° to attend to personal body hygiene.
• Postoperatively the limb is held in a strong posterior plaster slab, and
compression is maintained for 3 to 4 weeks.
• The appliance and sutures are then removed and a fresh elbow plaster cast
in the best position is worn till the fusion is solid radiologically in 4 to 6
months.
Arthrodesis

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