This document summarizes information about tuberculosis (TB) that affects joints, including the hip, knee, ankle, shoulder, elbow, and wrist. It discusses the pathology, pathogenesis, clinical presentation, investigations, and management of TB in each of these joints. For management, it describes the use of anti-tubercular therapy along with immobilization, exercises, and in some cases, surgical interventions like synovectomy, joint debridement, or arthrodesis. The goal of treatment is to relieve symptoms, heal the infection, and restore function, while avoiding unacceptable positions of fixation or recurrence of disease.

1. TB HIP

2. POST GRADUATE SEMINAR
TOPIC:- TB HIP & OTHER JOINTS
Date- 02-03-2016
Presenter-
Moderator-
Dr. Baharul Islam Choudhury Dr. M.
Gayan
PGT, Orthopedics Asst.
Proff

3. PATHOLOGY & PATHOGENESIS
 Any osteo-articular TB is the result of hematogenous dissemination
from a primarily infected visceral focus.
 Reach the joint space via bloodstream through subsynovial vessel
or from the lesions in the epiphyseal bone.
 Destructions begins peripherally
 The initial focus starts in the metaphysis in growing age or the end
of the bone in adult.
 The articular cartilage loses its nutrition & attachment when
subchondral region is involved.

4.  Synovial membrane become swollen & congested with synovial
effusion.
 Granulation tissue from synovium extends to joint.
 “Pannus” is formed at the periphery by the granulation tissue.
 “Rice bodies” in the joint.
 “Kissing lesion” on each side of the joint.

5. THE TUBERCLE

7. TB HIP

18. TB KNEE

24. TB ANKLE
 The incidence of ankle TB is around 5%.
 The initial focus may start in the synovium or as an erosion in the distal
end tibia, malleoli or talus.
 Pain ,limp & swelling are the earliest features.
 Swelling is mostly in front of the joint or sometime
around the malleoli or tendo achilles insertion.
 The ankle is held in plantar flexion.
 In long standing cases there may be ant. dislocation
with gross destruction of bone & ligaments.
 Radiologically during active stage there
will be marked osteoporosis with or without
osseous erosion & bony destruction.
 There may be sinus formation with
concomitant secondary infection.

25. TB SHOULDER
 The disease is rare constituting nearly 2% .
 Originates from the head of humerus, glenoid, & rarely from the
synovium.
 Painful limitation of abduction & ext rotation occur early.
 Marked wasting of deltoid
 Marked destruction & atrophy upper end of
humerus & glenoid & shoulder undergo
fibrous ankylosis.
 Very rarely there may be cold abscess
or sinus formation.
 In untreated cases humerus is fixed
against glenoid in adduction.
 Radiologically generalized rarefaction
with erosion of articular margin or destruction
of upper end of humerus & glenoid.
 There may be inferior subluxation
in advanced cases
.

26. TB ELBOW
 Elbow constitutes nearly 5% of skeletal TB.
 Starts fom the olecranon or lower end of humerus, or sometimes fro
synovium & upper end of radius.
 Onset is insidious accompanied by pain , swelling & limitation of
movements.
 Swelling is maximally at the back of elbow.
 In active stage stage elbow is held in flexion.
 Marked wasting of arm & forearm muscle.
 Enlargement of axillary lymph nodes.
 Radiologically marked destruction of bone
in lower end of humerus & olecranon.
 With marked destruction of bone & ligament
develop pathological posterior dislocation

27. TB WRIST
 Disease may starts in the synovium & very soon get disseminated in
the whole carpus.
 The disease may spread to the neighboring flexor & extensor tendon
sheath.
 Abscess & sinus formation & regional lympoh
node enlargement are common.
 Pain, swelling , limitation of movement&
palmarflexion deformity.
 Destruction of bones & ligaments leads to
anterior subluxation or dislocation.
 Radiologically there will be demineralization,
marginal erosion & diminution of joint spaces

28. TB SMALL JOINT
Develop in juxta-articular bone or in the synovium.
Finger joints are more common than toe joints & M-P joints
are more involved than I-P joints.
Spindle shaped swelling ( Spina ventosa) with flexion defotmity.

29.  A)- Routine examination of blood & ESR.
 B)- X-Ray
 C)- Mantoux test
 D)- Biopsy
 E)- Synovial fluid analysis
 F)- Smear & Culture
 G)- Isotope Scintigraphy
 H)- Serological Investigation
 I)- CT Scan
 J)- MRI
 K)- USG

30. MANAGEMENT
 TB HIP-

33. SURGICAL MANAGEMENT
 Indication-
> If response to conservative treatment is not favorable
> If the outcome is unacceptable.
A)- Synovectomy with or without joint debridement-
Remove hypertrophied synovium & inner surface of
thickened capsule.
Remove any loosened piece of articular cartilage, rice
bodies, debris, sequestra.
P/O triple drug therapy + intermittent exercises for 4-6 wks.-
> ambulation with braces for 3-6 months.

34.  B)- Arthrodesis-

35.  Arthrodesis-

37. Replacement Arthoplasty

38. SURGICAL APPROCHES
 Smith Peterson antero-lat approach
 Transverse anterior approach

39.  TB KNEE-

43. Arthrodesis

46. Management of TB Ankle
Treatment is basically done with ATT & immobilization with
below knee pop cast or a suitable orthosis.
Patient is ambulatory with crutches for 8- 12 wks & then guarded
weight bearing is encouraged with plaster or orthosis for 2 yrs
.
50% would heal with full ROM, 30% heal with useful ROM,
20% with painless gross ankylosis.
Surgery is indicated cases not
responding with ATT & rest.
Synovectomy, +/- joint debridement for synovitis
& early arthritis.
In painful ankylosis or pathological
subluxation/ dislocation, ARTHRODESIS in
plantigrade or 5 degree plantar flexion.

47. Management of TB Shoulder
In addition to general treatment of skeletal TB, shoulder is
immobilized in plaster shoulder spica in 70-90 degree of Abduction,
30 degree of flexion, 30 degree of internal rotation.
After 3 months plaster spica is replaced by abduction
frame. Being a non weight bearing joint, sound fibrous ankylosis is
acceptable.
Surgery ( arthrodesis, excision arthroplasty) may be
indicated in uncontrolled or recurrence cases.

48. Management of TB Elbow
In addition to general treatment & ATT , elbow is given
rest in 90 degree of flexion & midprone position for 6-9 months.
Active assisted exercises are started as soon as pain subsides.
Functionally satisfactory results are obtained in large
majority.
Surgery( Excision arthroplasty) is justified when the
disease has healed with elbow in unacceptable position, or patient
who is impelled to obtain a mobile joint.
(Arthrodesis) is rarely indicated where heavy manual
strength is the primary aim.
For unilateral cases 90 degree of flexion is desirable.
For bilateral one on 110 degree of flexion & other on 65 degree.

49. Management of TB Wrist
The treatment is essentially chemotherapy, correction of
deformity & splintage in 10-15 degree of dorsiflexion & forearm in
midprone.
If there is no subluxation or dislocation, plaster cast is
replaced with plastic/ metallic corset & active exercises should be
encouraged.
The splintage is continued for 12-18 months.
Surgery ( Synovectomy) is indicated in nonresponsive cases or
whenever any doubt.
Arthrodesis ( 10-15 deg of dorsiflexion, 5 deg radial deviation &
midprone position) is treatment of choice when there is
> Painful ankylosis
> History of recrudescence of infection
> Sound ankylosis in awkward position.

50. THANKING YOU