This document discusses tuberculosis of the knee joint. It begins by providing background on skeletal tuberculosis and noting that the knee joint is the third most common site. It then describes the typical 3 stage progression of knee joint tuberculosis over 3-5 years from synovial involvement to joint destruction to repair. Key diagnostic signs and symptoms at each stage are outlined. Treatment approaches are also summarized, including use of antitubercular drugs, drainage of abscesses, traction, synovectomy, and arthrodesis.

1. Presented by-
Dr. Ashutosh Kumar
AP Dept of Orthopaedics
RMCH Bareilly.

2. • Skeletal Tuberculosis
– Ancient disease
– 2% of all Tuberculosis cases
– The most common form of skeletal TB is Pott’s disease
– The next most common form of musculoskeletal TB is tuberculous arthritis
• The knee joint
– the largest joint
– the largest intra-articular space
– third common site for osteoarticular tuberculosis
– accounts for nearly 10% of all skeletal tuberculous lesions

3. • 3 stages spanned over a period of 3 to 5 years
1.stage of onset lasted from one month to one year (synovial disease)
2.stage of destruction (lasting for one to 3 years) the disease progressed till
there was gross destruction of joint with deformity, subluxation,
contractures and abscess formation
3.stage of repair and ankylosis, occurring after 2 to 3 years of onset of the
disease

4. inflammatory granulation tissue
(Pannus)
Marginal Erosions
Joint Destruction
Ankylosis
Subluxation / dislocation
Fibrous
Bony
( healing, in spine, sec. infection )
Cold abscess
sinus

5. • Stage I: Synovitis
• Stage II: Early Arthritis
• Stage III: Advanced Arthritis
• Stage IV: Advanced Arthritis with Subluxation or
Dislocation

7. • Initial focus
– hematogenous dissemination in the synovium
– in the subchondral bone
– juxta-articular osseous focus.
• The synovial lesion may for many months remain purely as
tubercular synovitis.
• The synovial membrane gets congested, edematous and studded
with tubercles.

8. • The naked eye examination
– pinkish-blue or pinkish-gray appearance.
• The synovial lining becomes hypertrophied and thickened with
granulation tissue.
• The joint fluid in the initial stages is increased, serous, turbid yellowish and
may contain fibrinous flakes.

9. • In advanced stage of the disease
– tuberculous process becomes osteoarticular,
– the tuberculouse granulation tissue like the pannus erodes the
articular margins, destroys the bones
– involves the cruicate ligaments, periarticular tissues, capsule
and ligaments.

10. • In cases which start as osseous lesions, there may be
tuberculous abscess in
– subchondral bone
– epiphyseal bone
– metaphyseal region
• Abscess in the epiphyses and metaphyses may sometimes
be seen traversing the epiphyseal cartilage plate

11. • The onset and course is insidious
• The knee shows
– Swelling
• warm
• patellar tap is present due to synovial effusion
• the thickened synovium
– filling up all parapatellar fossa appreciated earliest in medial
parapatellar fossa.

12. • Tenderness is present to pressure is most marked at the
synovial reflection and along the joint line.
• When the arthritis has set
– movements are grossly restricted,
– painful
– accompanied by muscle
• regional lymphadenopathy.

13. • Quadricep muscle shows gross wasting
• In the neglected case,
– triple deformity

14. “Triple deformity”. Note flexion of the knee,lateral subluxation and lateral rotation of
tibia, and it’s posterior subluxation
33

15. • Once the flexion deformity established
– tensor fasciae lata exantuates the deformity.
• In long case
– Posterior capsule of the knee joint gets contracted

16. • Synovial stage
– Generalized osteoporosis and
– increased soft tissue swelling caused by
• synovial effusion,
• thickened synovium and capsule.
• As the arthritis sets
– loss of definition of articular surfaces,
– marginal erosions,
– diminution of the joint space and
– destruction of the bones forming the joint.

17. • In advance stage,
– gross destruction and deformation of bone ends,
– osteolytic cavities,
– tubercular sequestra and
– triple deformity may be seen

18. • Monoarticular affections
– rheumatic arthritis (in children)
– chronic traumatic synovitis due to chronic internal derangement of knee (e.g.
• meniscal tears, loose bodies,
• osteochondritis dissecans,
• Chondromalacia apatellae,
• discoid semilunar cartilage etc)
• Rheumatoid arthritis (in adults),
• subacute pyogenic arthritis/synovitis,
• hemarthrosis,
• dysenteric arthritis,
• villonodular synovitis,
• synovial chondromatosis,
• synovioma,
• foreign body granuloma.

19. • General
• Rest, Mobilization and Brace
• Abscess, Effusion and Sinuses
• Antitubercular Drugs
• Surgery
10

20. • Antitubercular drugs
• Traction
• Arthrotomy and synovectomy
• Arthrodesis( Charnley compression)
• Supracondylar femoral osteotomy

21. • General
- Build the general body resistance
- Hospitalization for complications , traction for deformity
correction
11

22. 12

23. CATEGORY
REGIMENS DURATION
1.New Cases -New sputum smear +
-Seriously ill ,sputum –ve
-Seriously ill ,EP
-Sputum negative
-EP not seriously ill
2(HRZE)3 + 4(HR)3 6 MONTHS
2.Retreatment
cases
-sputum positive relapse -2(HRZES)3+
1(HRZE)3
-5(HRE)3
8 MONTHS
-sputum positive failure
-sputum positive treatment after
default
3.MDR TB
Cases
6(9)K O Et C Z E /
18( O Et C E )
24 – 27 MONTHS

25. • Aspirated and one gram of streptomycin alone or combined with
injectable isoniazid is instilled at each aspiration.
• Open drainage of the abscesses
13

26. • Non operative treatment with antitubercular drugs is employed in
– tubercular synovitis
– children.
• Traction is applied to
– prevent (for correct) flexion and subluxation deformity and to
– keep the joint surfaces distracted.
• In addition to the systemic drugs, the joint may be aspirated

27. Double traction for triple deformity and medical
management / surgical management
35

28. • In the stage of synovitis,
– non operative or operative
– complete healing
– excellent range of movements.
 In advance arthritis with subluxation severe restriction of motion is
inevitable,
arthrodesis (in adults) in functioning position (5 to 10 degree of flexion) is
one of the option of treatment.

29. Charnley’s compression arthrodesis of knee
36

30. • With the quiescence of acute local signs, gently active and assisted knee
bending should be.
• Usually after 12 weeks of treatment the patient may be permitted
ambulation with suitable orthosis and crutches.
• After 6 to 12 months of treatment, in cases with favorable response, the
crutches or orthosis may be discarded.
• Unprotected weight bearing is usually permitted 9 to 12 months after the
start of treatment.

31. • In children with arthritis the deformity and subluxation is
corrected/minimized by
– employing double traction or
– rarely by corrective plasters.
• Arthrodesis of the grossly destroyed knee in children should be deferred till the
completion of growth potentioal fo the distal femur and proximal tibia.

32. • In the synovial stage
– arthrotomy and synovectomy should be carried out.
• In early arthritis,
– synovectomy,
– removal of loose/rice bodies, debris, pannus, loose articular
 cartilage and
– careful curettage of osseous juxtaarticular foci
• Postoperatively triple drug therapy,
– traction,
– intermittent active and assisted exercises,
– suitable brace ambulation should be continued

33. • In adults with advanced arthritis or in cases which resulted in painful fibrous
ankylosis during the process of healing, the knee joint may be treated by
arthrodesis.
• This option provides
– painless stable knee,
– prevents recrudescence,
– corrects deformity and the
– patients can do long hours of standing and walking.
 However it imposes a lot of restrictions in sitting, using
 public transport and many other social activities.