The document discusses tuberculosis of the knee joint. Some key points: - Skeletal TB accounts for 10-35% of extra-pulmonary TB cases, with the knee being the 3rd most common site after the spine and hip. - TB typically spreads to the knee hematogenously from a primary focus. Synovial involvement can initially cause only effusion before advancing to osteoarticular destruction. - Advanced cases are characterized by bone erosion, subluxation, fibrosis and ankylosis on x-ray. Synovectomy and antitubercular drugs can cure early cases while arthrodesis is used for advanced cases. - Prognosis is generally good with antituberc

1. TB KNEE
DR. ISHDEEP SINGH OBEROI
(PG-1)
Department of Orthopedics, SMS&R

2. ● SKELETAL TB ACCOUNTS FOR 10 TO 35 PERCENT OF
CASES OF EXTRAPULMONARY TUBERCULOSIS.
● AFTER LUNG AND LYMPH NODES,SKELETAL TB IS
THE NEXT COMMON TYPE.IT CONSTITUTES ABOUT
1-4% OF TOTAL TB CASES.(MORE IN HIV-INFECTED
PATIENTS)
● SKELETAL TB GENERALLY OCCURS DUE TO
HEMATOGENOUS SPREAD FROM A PRIMARY FOCUS.
● COEXISTING PULMONARY TB IS SEEN IN APPR.50%
CASES

3. ● KNEE: LARGEST JT IN THE
BODY HAVING LARGEST INTRA-
ARTICULAR SPACE
● 3RD MC SITE OF
OSTEOARTICULAR TB
● 10% OF ALL SKELETAL TB
LESIONS
SPINE>HIP>KNEE

5. PATHOLOGY
● INITIAL FOCUS OCCURS BY
1. HEMATOGENOUS DISSEMINATION IN THE SYNOVIUM
2. JUXTA ARTICULAR OSSEOUS FOCUS
3. IN THE SUBCHONDRAL BONE
THE SYNOVIAL LESION MAY FOR MANY MONTHS REMAIN PURELY
AS TUBERCULAR SYNOVITIS

6. SYNOVIAL MEMBRANE(SM) GETS
CONGESTED, EDEMATOUS &
STUDDED WITH TUBERCLES
NAKED EYE EXAMN: PINKISH
BLUE/GREY APP.
SM BECOMES HYPERTROPHIED &
THICKENED W GRANULATION TISSUE

7. JOINT FLUID IN INITIAL STAGES IS
INCREASED, SEROUS, OPALESCENT,
TURBID, YELLOWISH AND MAY
CONTAIN FIBRINOUS FLAKES.
IN ADVANCED STAGES, TUBERCULAR
PROCESS BECOMES
OSTEOARTICULAR, ERODES:
● ARTICULAR MARGINS,
● BONES,
● CRUCIATE LIGS,
● PERIARTICULAR TISSUE,
● CAPSULE.

8. ● INTRA-ARTICULAR RICE BODY FORMATION CAN
OCCUR IN CHRONIC INFLAMMATORY DISEASES SUCH
AS RA, TB ARTHRITIS, CHRONIC FUNGAL INFECTIONS,
SYNOVIAL CHONDROMATOSIS, PIGMENTED
VILLONODULAR SYNOVITIS, GOUT, OR SYSTEMIC
LUPUS ERYTHEMATOSUS
● RICE BODIES ARE MAINLY FORMED OF FIBRIN AND
ARE SEEN IN RELATION TO JOINTS, BURSA OR
TENDON SHEATHS.
● RICE BODIES ARE NON-SPECIFIC FINDINGS IN
CHRONIC INFLAMMATION THAT ARISE FROM
MICROINFARCTIONS WITH SYNOVIAL SHEDDING
ENCAPSULATED BY FIBRIN
WHAT ARE RICE BODIES?

9. CLINICAL FEATURES
ONSET/ COURSE : INSIDIOUS WITH USUAL
SYSTEMIC & LOCAL FEATURES OF TUBERCULOUS
DS
SWELLING, FILLING UP ALL PARAPATELLAR FOSSA
EARLIEST IN MEDIAL PARAPATELLAR FOSSA,
SUPRAPATELLAR, POPLITEAL FOSSA.
SWELLING : WARM, BOGGY/DOUGHY ( BEST
PALPATED ON MEDIAL SIDE OF KNEE)
PATELLAR TAP +VE IF SWELLING PREDOMINANTLY
DUE TO SYNOVIAL EFF.

10. C/F CONTD.
TENDERNESS MOST MARKED AT SYNOVIAL REFLECTIONS+ALONG JT
LINE.
IN SYNOVIAL DS, FOR A LONG TIME THERE MAYBE ONLY TERMINAL
RESTRICTION OF MOVEMENTS.
IN NEGLECTED CASES, DUE TO SPASM AND CONTRACTURE OF
HAMSTRINGS ( B.F ) LEG PULLED INTO FLEXION, POST LAT SUBLUXATION,
EXT ROT & ABDUCTION.
ONCE SET IN, TFL THROUGH ITB FURTHER EXANTUATES.
POST CAPSULE GETS CONTRACTED IN LONG STANDING CASES

11. DIAGNOSIS
BLOOD : RELATIVE LYMPHOCYTOSIS, LOW HB, ↑↑ESR, ↓GLUCOSE, ↑PROTEIN
MANTOUX TEST : +VE REACTION IS PRESENT IN A PT WITH TUBERCULOUS DS
OF SOME STANDING (ONE TO 3 MONTHS), -VE TEST IN GENERAL RULES OUT
THE DS.
BIOPSY:EPITHELOID CELLS SURROUNDED BY LYMPHOCYTES IN THE
CONFIGURATION OF A TUBERCLE(EVEN WITHOUT CENTRAL NECROSIS OR
PERIPHERAL FOREIGN BODY GIANT CELLS) IS AN ADEQUATE HISTOLOGICAL
EVIDENCE.
GUINEA PIG INOCULATION: PUS INJECTED INTO THE ANIMAL
INTRAPERITONEALLY, +VE IF TUBERCLES APPEAR IN 5-8WKS.
UNECONOMICAL BUT PERHAPS MOST RELIABLE PROOF.

12. SMEAR & CULTURE: MAYBE SENT FOR AFB ( LOWENSTEIN JENSEN )
ISOTOPE SCINTIGRAPHY: COMMON IN AFFLUENT COUNTRIES, USES TC,
GA, IN. TC IS EXTREMELY SENSITIVE BUT LACK OF SPECIFICITY, MAY
SHOW INCREASED UPTAKE IN OSTEOPOROTIC #S,INFECTIONS,STRESS #,
HEALING TRAUMATIC #S.
SEROLOGY: ELISA FOR AB TO MYCOBACTERIAL AG -6, 94% SENSITIVITY,
100% SPECIFICITY.
GENXPERT PCR : 95% SENSITIVITY, 96% SPECIFICITY.
QUNTIFERON TB GOLD : 84% SENSITIVITY, 95% SPECIFICITY.

14. RADIOGRAPHIC FINDINGS
XRAY :

16. TUBERCULAR ARTHROPATHY CAN BE DIVIDED ON THE BASIS OF
RADIOLOGICAL FEATURES:
1. EARLY STAGES (STAGE OF SYNOVITIS AND ARTHRITIS)
● PERIARTICULAR DEMINERALIZATION
● JOINT SPACE WIDENING (JOINT EFFUSION)
● MILD SUBCHONDRAL EROSION
2. LATE STAGES (STAGE OF EROSION AND DESTRUCTION)
● GRADUAL NARROWING OF JT SPACE(INV OF ARTICULAR CARTILAGE)
● SEVERE SUBCHONDRAL EROSION AND DESTRUCTION
● PATHOLOGICAL SUBLUXATION AND DISLOCATION
● FIBROUS ANKYLOSIS
● ATROPHIC CHANGES IN BONES LEADING TO ATROPHIC ARTHROPATHY

18. ± KNEE VALGUS =
QUADRUPLE
DEFORMITY
T- TUBERCULOSIS
R-RA
I-ITB CONTRACTURE
P-POLIO
L-LOW CLOTTING CAPACITY
E-EXCESS
BLEEDING/HEMOPHILIA

19. MODERN IMAGING TECHNIQUES
CT SCANS: HELPFUL IN DEMONSTRATING LYTIC CAVITIES IN BONE AND
MARGINAL EROSIONS BEFORE THESE CAN BE SEEN ON XRAYS.
MRI : WOULD CONFIRM WHATEVER ONE CAN SEE IN PLAIN XRAYS & CT.
ALSO SHOWS PRESDESTRUCTIVE LESIONS LIKE DEMINERALIZATION,
EDEMA, INFLAMMATION OF THE BONE IN ACTIVE DISEASE.
ROLE OF GADOLINIUM AS A CONTRAST MEDIUM IN MRI HAS NOT YET
BEEN FULLY ESTABLISHED IN INFECTIVE LESIONS.
USG: BEEN EMPLOYED BY VARIOUS WORKERS TO ESTIMATE THE
PRESENCE OF SOFT TISSUE ABSCESSES AND ITS BEHAVIOUR UNDER
TREATMENT.

20. PROGNOSIS
USE OF ATT HAS REVOLUTIONIZED THE OUTCOME OF RX OF BONE & JT TUBERCULOSIS.
DEATHS DUE TO UNCONTROLLED DS, MENINGITIS, MILIARY TB, AMYLOIDOSIS,
PARALYSIS ARE NOW RARE.
IF DIAGNOSED EARLY, TREATED VIGOROUSLY, HEALING CAN BE ACCOMPLISHED
WITHOUT RESIDUAL ANKYLOSIS.
IN THE STAGE OF SYNOVITIS, NON OPERATIVE ( OR OPERATIVE WHEN INDICATED)
TREATMENT OFTEN RESULTS IN COMPLETE HEALING WITH AN EXCELLENT RANGE OF
MOVEMENTS.
IN ADVANCED ARTHRITIS WITH SUBLUXATION SEVERE RESTRICTION OF MOTION IS
INEVITABLE, THEREFORE, ARTHRODESIS ( IN ADULTS ) IN FUNCTIONING POSITION ( 5-10
DEGREE OF FLEXION) IS ONE OF THE OPTIONS OF TREATMENT

21. TREATMENT
NON-OPERATIVE RX WITH ANTITUBERCULAR
DRUGS IS EMPLOYED IN TUBERCULAR
SYNOVITIS AND IN CHILDREN.TRACTION IS
APPLIED TO PREVENT( OR CORRECT) FLEXION
AND SUBLUXATION DEFORMITY, AND TO KEEP
THE JOINT SURFACES DISTRACTED.
IN ADDITION TO THE SYSTEMIC DRUGS, THE
JOINT MAYBE ASPIRATED ( WHEN ACCOMPANIED
BY EXCESSIVE EFFUSION) AND STREPTOMYCIN
AND ISONIAZID IN SOLUTION MAYBE INSTILLED
INTRA-ARTICULARLY ONCE WEEKLY.

23. ● WITH THE QUIENSCENCE OF ACUTE LOCAL SIGNS, GENTLE
ACTIVE AND ASSISTED KNEE BENDING EXERCISES SHOULD BE
CARRIED OUT INTERMITTENTLY
● AFTER 12 WEEKS, MAYBE PERMITTED AMBULATION WITH
SUITABLE ORTHOSIS / CRUTCHES.
● AFTER 6-12 MONTHS, IF SUITABLE RESPONSE PRESENT,
CRUTCHES MAYBE DISCARDED
● AFTER 9-12 MONTHS, UNPROTECTED WT BEARING IS USUALLY
PERMITTED.

24. OPERATIVE RX
IN SYNOVIAL STAGE, IF DS IS NOT RESPONDING FAVORABLY, OR THE DIAGNOSIS IS UNCERTAIN EVEN
AFTER SEMI-INVASIVE PROCEDURES, ARTHROTOMY AND SYNOVECTOMY SHOULD BE CARRIED OUT.
IN ADDITION, REMOVAL OF LOOSE/RICE BODIES, DEBRIS, PANNUS, LOOSE ARTICULAR CARTILAGE,
AND CAREFUL CURETTAGE OF OSSEOUS JUXTA-ARTICULAR FOCI SHOULD BE CARRIED OUT.
POST OPERATIVELY, TRIPLE DRUG THERAPY, TRACTION, INTERMITTENT ACTIVE AND ASSISTED
EXERCISES, SUITABLE BRACE AMBULATION SHOULD BE CONTINUED.
IN ADULTS W ADVANCED ARTHRITIS OR INCASES WHICH RESULTED IN PAINFUL FIBROUS ANKYLOSIS
DURING THE PROCESS OF HEALING, KNEE JT MAYBE BE TREATED BY ARTHODESIS.
PROVIDES PAINLESS STABLE KNEE, PREVENTS RECRUDESCENCE CORRECTS DEFORMITY, AND PTS
CAN DO LONG HOURS OF STANDING AND WALKING

26. IF THE DS HAS HEALED W A
PAINLESS ROM(MIN - 20
DEGREE) IN AN UNACCEPTABLE
POSITION, A SUPRACONDYLAR
FEMORAL OSTEOTOMY MAYBE
PERFORMED.
FREQUENTLY RESULTS IN A
MOBILE JT USEFUL FOR
ANOTHER 10-15YRS.

27. SYNOVECTOMY
● The incisions
● Midline anterior or
● Medial/lateral parapatellar incision
● Some surgeons prefer two parapatellar incisions.
● Expose from the suprapatellar pouch proximally to the insertion of ligamentum
patellae distally
● Skin, superficial fascia, deep fascia are cut
● Quadriceps expansion is cut about half to one cm away from the patella.
● By sharp dissection, a plane of cleavage is developed between the quadriceps
expansion and suprapatellar synovial pouch.
● Excise the thickened synovial membrane starting from its proximal borders the
suprapatellar pouch, articular margins of femoral and tibial condyles.
● Flex the knee joint to 90 degrees and inspect.Remove any loose bodies
● Remove as much as an unhealthy synovial membrane that can be removed from the
cruciate ligaments and intercondylar fossa.
● Rotating tibia to either side may maximize the exposure of the membrane
● Above maneuver also helps inspection of menisci.
● Any obstructing intra-articular lesion or extra-articular adhesions should be cut’.
When required, capsulectomy or capsulotomy is performed, to obtain the desired
flexion on the operation table. The goal is to achieve a minimum of 90 degrees of
flexion at the knee.
● The wound is closed over suction drainage

28. SYNOVECTOMY + DEBRIDEMENT
● IN CASES OF INFECTION, SUCH AS TUBERCULOSIS THE DISEASE MIGHT HAVE SPREAD
BEYOND THE EXTENT OF THE SYNOVIAL MEMBRANE.
● IN SUCH CASES, DEBRIDEMENT OF THE JOINT IS ALSO UNDERTAKEN. THIS INVOLVES
REMOVAL OF PANNUS, CURETTAGE OF DESTROYED BONE
● IF THE CAVITIES ARE LARGE, THESE MAY BE FILLED UP WITH CANCELLOUS BONE
GRAFTS FROM THE NEARBY HEALTHY BONE. ALL THE DESTROYED TISSUE LIKE MENISCI,
LOOSE AND DESTROYED ARTICULAR CARTILAGE, DESTROYED CAPSULE AND
LIGAMENTS MAY BE CAREFULLY REMOVED.

29. POSTOPERATIVE CARE FOR SYNOVECTOMY KNEE
THE LIMB IS KEPT ELEVATED ON A PILLOW WITH THE KNEE JOINT KEPT IN ABOUT 5 TO 10
DEGREES OF FLEXION WITH THE HELP OF A ROLLED TOWEL OR A SMALL PILLOW BEHIND
THE KNEE.
EXERCISES OF THE ANKLE AND STATIC QUADRICEPS EXERCISES ARE STARTED THE SAME
DAY.
KNEE BENDING EXERCISES ARE STARTED AFTER 24-48 HOURS AFTER REMOVAL OF
SUCTION DRAIN. THE PATIENT MAY BE PUT ON CONTINUES PHYSIOTHERAPY.
QUADRICEPS STRENGTHENING IS CONTINUED AND WEIGHT BEARING IS GRADUALLY
ADDED.

30. ARTHRODESIS
INDICATIONS:
● ADVANCED TUBERCULAR ARTHRITIS
● TUBERCULAR ARTHRITIS WITH TRIPLE DEFORMITY
● GROSS INSTABILITY
● PAINFUL ANKYLOSIS AFTER EARLIER OPERATIONS
● PTS WITH FAILURE OF PRIOR JOINT REPLACEMENT

31. CHARNLEY COMPRESSION CLAMP
CHARNLEY RECOMMENDED COMPRESSION
ARTHRODESIS IN TUBERCULOUS KNEE JT IN
CHILDREN
DEGREE OF COMPRESSION: 1 ROUND ,½ TO ⅓
OF THE ROUND 24HRLY FOR ABOUT 4-6 WKS,
AFTERWARDS UPTO GROIN PLASTER CAST
APPLIED EXCLUDING FOOD AND ANKLE.
PLASTER TILL GROIN SHOULD BE USED IN
BEST POSSIBLE FUNCTIONAL POSITION FOR 8-
12 WEEKS.
WT BEARING IN CAST COMMENCED 5-6WEEKS
AFTER OPERATION
WALKING PLASTER IS RETAINED FOR 3-
6MONTHS

32. ARTHROPLASTY FOR TUBERCULOUS ARTHRITIS
● BESSER, WRAY, ROY (1987) PERFORMED ARTHROPLASTY
INADVERTENTLY IN PREOPERATIVELY UNSUSPECTED CASES OF TB
KNEE.
● IN GROSSLY DESTROYED PAINFUL KNEE, W OR W/O DEFORMITY,
TRADITIONAL RX HAS BEEN ARTHRODESIS IN THE BEST FUNCTIONAL
POSITION.
● HOWEVER, IMPOSES MULTIPLE RESTRICTIONS IN SITTING, PUBLIC
TRANSPORT,MANY OTHER SOCIAL ACTIVITIES.
● ONCE THE KNEE ARTHROPLASTY IS INFECTED NO SATISFACTORY
OUTCOME IS ACHIEVED BY RESECTION ARTHROPLASTY, ARTHRODESIS
OR REVISION ARTHROPLASTY.
● MOST AUTHORS SUGGEST, THIS OPERATION ATLEAST 3-5 YEARS AFTER
THE LAST EVIDENCE OF INFECTION.

33. STRING TEST: A NEW TOOL FOR TUBERCULOSIS
DIAGNOSIS AND DRUG-RESISTANCE DETECTION IN
CHILDREN

35. REFERENCES
Imperiale BR, Nieves C, Mancino B, Sanjurjo M, Tártara S, Di Giulio ÁB, Palomino JC, Morcillo NS, Martin A. String test: A
new tool for tuberculosis diagnosis and drug-resistance detection in children. Int J Mycobacteriol. 2018 Apr-Jun;7(2):162-
166. doi: 10.4103/ijmy.ijmy_54_18. PMID: 29900894.
Olivia J B, Demetri M E, James V B. Knee Arthrodesis: The Fate of the Contra Lateral Knee. Nov Tech Arthritis Bone Res.
2018; 3(1): 555604. DOI: 10.19080/NTAB.2018.03.555604
Tuberculosis of the Skeletal System - Dr. S.M. Tuli

36. THANKYOU!