This document discusses tuberculosis (TB), which is caused by Mycobacterium tuberculosis bacteria. It notes that India has the highest TB burden in the world, accounting for 20% of global cases. Over 1.8 million people develop TB in India each year, with over 5000 new cases and 2000 deaths daily. Skeletal TB, which affects the bones and joints, constitutes 1-3% of extra-pulmonary TB cases. The hip joint is the second most commonly affected osteoarticular site after the spine. Clinical features, investigations, radiographic findings, and management of TB of various bones and joints such as the spine, hip, knee, shoulder, and skull are described in detail.

1. DR VENKATESH V
ASSISTANT PROFESSOR
DEPT OF ORTHOPEDICS
SSMCH

2.  Tuberculosis is a chronic
granulomatous infectious disease
caused by Mycobacterium
Tuberculosis (a gram positive acid fast
bacilli).
 Transmitted through the air borne spread
of droplet nuclei produced by patients
with infectious pulmonary tuberculosis.

3.  India: highest TB burden in world
(accounts for 1/5 (20%) of global burden)
 Every year  1.8 millions develops TB
 Every day about 5000 people
develop disease.
 2 persons die of TB every 3 min.
 More than 1000 people die every day.

4.  Increased incidence has been noted
with prevalence of AIDS.
 In India EPTB (extra pulmonary
tuberculosis) form 10-15% of all types of
TB.
 Amongst EPTB, Lymph node TB is
the commonest.
 TB of bone and joints constitutes 1-3% of
Extra-pulmonary TB of which the most
commonly involved is the Spine
constituting 50% of all Skeletal
Tuberculosis.

5.  Skeletal tuberculosis (TB) refers to
TB involvement of the bones and/or
joints.
 It is an ancient disease; features
of spinal TB have been
identified in Egyptian mummies
dating back to 9000 BC

6. Pulmonar
y (85-90
%)
Extra-
Pulmonary
(10-15 %)
Lymph nodes
(m/c),
Abdominal
etc.
Skeletal (1-3
%)
TB Spine
(Pott’s)
50%
TB Hip,
Knee,
Shoulder
etc.

7.  Tubercular affection of joints:
Hip Joint
Knee joint and Triple deformity
Shoulder joint and Caries Sicca
Elbow joint, Wrist and Carpus, Sacroiliac
joints
 Tubercular Osteomyelitis (Long and
Flat Bones)
 Tubercular dactylitis (Spina Ventosa)

8.  Insidious onset (c/w pyogenic infections)
 Low grade fever
 Weight loss
 Night sweat
 Movement restriction, muscle wasting, regional
lymph node involvement and neurologic
symptoms
 Weight bearing joints like hip, knee and ankle
are commonly involved, though any part of the
skeleton can get involved

10.  Ball and socket type of synovial joint.
 Fibrocartilaginous labrum attached to
acetabulum, makes the socket deeper.
 Considerable part of articular surface of
spherical femoral head remains uncovered.
 Opening of acetabulum directed laterally,
downwards
(300) and forward (300).
 Femoral neck directed medially, upward
and anteriorly.
 Angle of anteversion in adult 10-300, neck shaft
angle around 1250.

12.  2nd most common
osteoarticular TB (next only
to spinal TB)
 Commoner in males
INTRODUCTIO
N:
PATHOGENESI
S:
• Invariably secondary to primary
site elsewhere (lungs, LNs of
mediastinum,mesentry or
cervical,kidney etc)
• The “tubercle” is the microscopic
pathological lesion with central
necrosis surrounded by epitheloid
cells, giant cells and mononuclear
cell.

13. Caseating exudative type: when
caseating necrosis and cold abscess
formation predominates
Proliferating type: where cellular proliferation
predominates with minimal caseation,
tuberculosis granuloma is the extreme form
of this type
(Former is common in children & latter in
adults)

15. Babcock's triangle :
A relatively radiolucent seen
on an anteroposterior
radiograph of the hip in the
subcapital region of the
fermoral head. It is an area
of loosely arranged
trabeculae noted between
the more radiodense lines
of the normal bony
trabeculae groups.
Tuberculosis of hip joint The
disease may start in
epiphysis, Babcock’s
Triangle, acetabular roof or
in synovium.

16. Lesions of upper end
femur
Involves joint rapidly
Destruction of articular
surface of head &
acetabulum

28.  General: pallor, emaciation, LNs, signs of pulm
TB
 Gait: antalgic, trendelenburg
 Inspection: deformity of limb, wasting of thigh
& gluteal muscles, swelling around hip
 Palpation: confirmation of above findings, muscle
spasm of lower abdomen & adductors of thigh,
joint line tenderness, shift of GT
 Movements: fixed deformities, painful ROM
 Measurements: Apparent
lengthening/shortening, true shortening (Due to
fixed deformities secondary changes in spine (lordosis,

29. Group 1 Painless ROM in all directions
Group 2 Painless range of flexion 35-900
Group 3 Flexion <35 0 with fibrous ankylosis
Group 4 Bony fusion

33.  Hb% (anaemia)
 TC: increased lymphocytes
 DC: lymphocytes – monocyte ratio (5:1)
normal.
 ESR raised in active stage
 Mantaux test (in children)
 TB Elisa (usually IgM. Titre is active) : sensitive
in 60-80%, but may be negative in patient with
advanced disease.
 RNA and DNA based PCR studies
 X-ray hip, AP and lateral and X-ray chest PA

38.  Minimum of 6 months is a must but some
prefer 9 months regime.
 Both 6 and 9 months regime appear to
give acceptable relapse rates of within
2%.
 Except in pediatric cases, relapses are not
drastically improved by extending treatment
to 12 months.
 Prolonged treatment is indicated:
• If surgical debridement is indicated but
cannot be done.
• Co-existent HIV/AIDS also necessitate
prolonged treatment. (Interaction between 1st
line ATT and antiretroviral therapy can result in
complications)

42. Side effects Management
Rifampin Rash Observe patient / stop drug if significant
Liver dysfunction Monitor AST / limit alcohol consumption / monitor for
hepatitis symptoms
Flulike syndrome Administer at least twice weekly / limit dose to 10 mg/kg
(adults)
Red-orange urine Reassure patient
Drug interactions Consider monitoring levels of other drugs affected by
rifampin, especially with contraceptives, anticoagulants,
and digoxin/avoid use the protease inhibitors.
Isoniazid Fever, chills
Hepatitis
Stop drug
Monitor AST/limit alcohol consumption/monitor for
hepatitis symptoms/educate patient / stop drug at first
symptoms of hepatitis (nausea, vomiting, anorexia, flulike
syndrome)
Peripheral neuritis Aminister vitamin B6
Optic neuritis Administer vitamin B6/ stop drug
Seizures Administer vitamin B6

43. Pyrazinamide Monitor AST/limit daily dosage to 15-
30mg/kg/discontinue with signs or
symptoms of hepatitis
Hyperuricemia Monitor uric acid level only in cases
of gout or renal failure.
Ethambutol Optic neuritis Use lower doses when possible.
Monitor visual acuity (eye chart) and
red-green colour vision (Ishihara
chart). With any visual complaint stop
Streptomycin, Ototoxicity,
Amikacin, Renal toxicity
Capreomycin
drug and get ophthalmologic
evaluation.
Limit dose and duration of therapy as
much as possible. Monitor BUN and
serum creatinine levels and conduct
audiometry as needed

47. 

57. 




59. BRITTAIN’
S

62. Soon after
surgery
5 years
later

68.  Largest intra-articular space
 Involved in about 10 % of osteo-
articular tuberculosis
 Any age group
 Symptoms - pain, swelling, palpable synovial
thickening and restriction of mobility.
Tenderness in the medial or lateral joint line
and patello- femoral segment of the joint
 The initial focus may be in synovium or
subchondral bone of distal femora, proximal
tibia or patella.

69. Osteoporosis, soft tissue swelling, joint /
bursa effusion.
Distension of supra-patellar bursa on
lateral radiograph of knee
Infection in childhood can lead to accelerated
growth and maturation resulting in big
bulbous squared epiphysis
Widening of the inter-condylar notch
(synovitis)

70. Periarticular
osteopenia
Erosions
Symmetric
reduction of joint
space

71.  Loss of definition of articular
surfaces
 Marginal erosions
 Decreased joint space
 Osteoporosis
Osteolytic cavities with or without
sequestra formation
Marked reduction of joint space
Destruction and deformity of joints
In advanced cases, there is triple deformity of
the knee may occur

72. • Peripherally
enhancing
joint collection
• Marginal
erosion
T1 PC non fat
sat

73. • Marrow
edema
• Synovial
thickening
T2

74. Juvenile rheumatoid arthritis
Villonodular synovitis
Osteochondritis dissecans
Hemophilia
Biopsy of the synovial membrane and
aspiration of the joint fluid followed by smear
& culture can confirm the diagnosis

75.  Components:
Flexion
External rotation
and valgus at
knee
Associated with
posterior
subluxation of

77.  Triple Deformity of knee is seen in
: "TRIPLE“:
T - TUBERCULOSIS ( MOST COMMON
CAUSE ) R - RHEUMATOID ARTHRITIS
I - ILIOTIBIAL BAND
CONTACTURE P - POLIO
L - LOW CLOTTING CAPACITY
E - EXCESS BLEEDING / HEMOPHILIA

78.  Double Traction (90-90): For
Supple deformities
 Anti- tubercular Therapy

79.  Surgical options include:
Debridement and
Synovectomy
Arthrodesis
Total Knee Replacement

81.  Rare entity
 More frequent in adults
 Incidence of concomitant
pulmonary tuberculosis is high
 The classical sites are:
 head of humerus,
 glenoid,
 spine of the scapula,
 acromio-clavicular joint,
 coracoid process and rarely synovial
lesion.

82. Initial tubercular destruction is typically
widespread (because of the small
surface contact area of articular
cartilage)
Symptoms –
severe painful movement restriction
particularly abduction and external

83.  Radiologically,
 osteoporosis
 erosion of articular margins (fuzzy)
 osteolytic lesion involving head of
humerus, glenoid or both
 The lesion may mimic giant cell tumor.
 The joint space involvement and
capsular contracture are seen early in
the disease.
 Sinus formation
 Inferior subluxation of the humeral head

84.  Deformity
 Erosions
 Osteopenia
 Peri-articular
calcifications

85. • Erosion
• Synovial proliferation
• Subdeltoid collection

86. Atrophic type of tuberculosis of the shoulder
Benign course
Without pus formation
Small pitted erosions on the humeral head
Classical dry type is more common in adults
fulminating variety with cold abscess or
sinus formation is more common in
children

87. Caries sicca: there is erosion and
destruction of humoral head and glenoid
cavity with soft tissue swelling, along with
fibrotic opacites in the right upper and

88. Differential diagnosis -
Peri-arthritis of the shoulder
Rheumatoid arthritis
Post-traumatic shoulder stiffness
Aspiration of the shoulder and FNAC might
be necessary to establish the diagnosis.
The patients usually respond well to
anti- tubercular drugs.

90.  Tubercular dactylitis
 primarily a disease of childhood
 affects short tubular bones distal to tarsus
and wrist
 bones of the hands are more frequently
affected than bones of the feet
 proximal phalanx of the index and middle
fingers and metacarpals of the middle and ring
fingers being the most frequent locations
 Frequently present as marked swelling on
the dorsum of the hand and soft tissue
abscess is normally a common feature

92. Often follows a benign course without pyrexia
and acute inflammatory signs, as opposed to
acute osteomyelitis.
Plain radiography is the modality of choice
for evaluation and follow-up.
The radiographic features –
Cystic expansion of the short tubular bones
have led to the name of "spina ventosa" being
given to tubercular dactylitis of the short bones
of the hand.
spina - short bone and
ventosa - expanded withair

93. Bone destruction and fusiform expansion of
the bone
It is most marked in diaphysis of metacarpals
and metatarsals in children
Periosteal reaction and sequestra are
uncommon.
Healing is gradual by sclerosis.
Differential diagnosis –
Syphilitic dactylitis – bilateral and symmetric
involvement, more periostitis, less soft
tissue swelling.
Chronic pyogenic osteomyelitis and mycotic

94. Tuberculou
s

95. Spina
ventosa

96. • Rare entity
• May be localized and well
defined
• Or may be more diffuse
• Associated with cold abscess

97. 1)Lateral radiograph shows large circumscribed lytic lesion
in frontal bone
2)AP radiograph demonstrates a large frontoparietal lytic
lesion suggestive of diffuse spreading type
3) Frontal radiograph shows a lytic lesion with a sclerotic
margin

99. Skull -
Frontal bone most common site
Ill-defined lytic lesion may be the only
radiological feature seen with overlying cold
abscess (Potts' Puffy tumor)
Button sequestrum sometimes seen
Facial bones and mandibular involvement
is extremely rare

100. Pott’s puffy tumour – TB osteomyelitis of
skull with overlying abscess

101. Button
sequestrum

102.  Tubercular affection of tendons and
Bursae
 Tubercular Osteomyelitis
 Tuberculosis of Ribs and Flat bones
 Tubercular infection of Sacroiliac
joints and Pelvis (also read Weaver’s
Bottom)
 BCG Osteomyelitis/ Arthritis
 Atypical Mycobacterial infection

103. Also k/as Tubercular
Rheumatism
It is a form of Polyarthriris
occuring in patients suffering
from Tuberculosis,
commonly affecting the
Knee and Ankle joints