Tuberculosis of joint

Joint Lesions• One of the common cause of infectious arthritis

in developing countries

Never a primary lesion it is always a sequelae of pulmonary or lymph node tuberculosis

It can occur at any age.

Tuberculosis Diagnosis

long history

involvement of single joint

marked thickening of the synovium

marked muscle wasting

periarticular osteoporosis

+ve Mantoux test

TuberculosisClinical Features

contact with TB

pain, swelling, loss of weight

joint swelling

decrease ROM

ankylosis

deformity

Clinical featuresConstitutional

symptoms

Malaise

Loss of appetite/weight loss

Night sweats .

Night fever .

Specific features

Stiffness

Enlarged lymph nodes

Neurodeficit

Joint TB - InvestigationsPlain x-rays often normal

MRI can be helpful in diagnosis1

But there needs to be a high index of suspicion to request this

Aspiration of synovial fluid for TB culture

Synovial biopsyie tissue for TB culture should sent in saline

or waterHigher yield2

1. Desai.J Bone Joint surg Br.19942. osteoarticular TB in a general hospital in the last decade.ruiz.clin microbiol

infect.2003

Tuberculosis Investigation

FBC , ESR,

Mantoux

NOT IN:

MILIARY TB / RECENTLY VACCINATED/ ON STEROIDS / REDUCED IMMUNITY / FEVER

Xray -soft tissue swelling

-periarticular osteoporosis

-joint appear washed out articular space narrowing

Joint aspiration AAFB identified in 10-20% culture +ve in 50% of cases

Joint TB - ManagementStandard quadruple therapy*

Rifampicin

Isoniazid

Pyrazinamide

Ethambutol

*short course chemotherapy for spinal Tb.parthasarathy.journal of bone and joint surgery.1999

Radiographic features

Plain film

early stages (stage of synovitis and arthritis)

• periarticular demineralisation(osteoporosis)

• joint space widening (due to joint effusion)

• mild subchondral erosion

late stages (stage of erosion and destruction)

• gradual narrowing of joint space (there is involvement of articular cartilage)

• severe subchondral erosion and destruction• pathological subluxation and dislocation• fibrous ankylosis • atrophic changes in bones may occur and lead to

atrophic arthropathy (seen in shoulder joint as carries sicca) 

Tuberculosisdifferential diagnosis

transient synovitis

monoarticular RA .

haemorhagic arthritis

pyogenic arthritis

TB OF JOINTTB OF SHOULDER .

TB OF ELBOW .

TB OF WRIST .

TB OF HIP .

TB OF KNEE .

TB OF ANKLE .

TB OF SHOULDERUncommon .

Start as osteitis but rarely diagnosed ,untile arthritis has supervened

May be form absces and sinus .

Some cases have get fibrosis tendency or ankylosis .

If there is no exudate term used CARIES SICCA .

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 middle lobe.

CLINICAL FEATURES

Mainly in adult .

Complain of constant ache and stiffness for many months or years .

Wasting muscle especialy deltoid m .

Sinus may be present over the shoulder or in axilla .

Diffuse warmth and tenderness .

Limited movement and painful .

Axillary LN enlargment .

X-ray

Generaly rarefaction .

Usually with some erosion of joint surface .

There may be absces cavity in the humerus or glenoid with little or no periosteal reaction .

TREATMENT ;

Anti- TB drug + shoulder rested untile acute symptoms have settled , movement encouraged .

If there extensively destroyed :joint should be arthrodesed

TB OF ELBOW Pathology

Elbow is affected in about 10 % of pts with sk . tuberculosis

Start as synovitis or osteomyelitis , pts rarely seen untile arthritis supervenes

CLINCAL FEATURES :

Onset insidious with long Hx of aching and stiffness

SIGN ; muskle wasting

followActive stage :

joint is held flexed ,swellen ,warm ,diffusely tender ,

Movement limited accompanied with pain and spasm .

X-RAY :- Prei-articular osteoporosis .

- Joint erosion

-subchondral cystic lesions .

DIAGNOSIS :

Aspiration ,synovial biopsy and micobiological investigation

TTT :

General antituberculous treatment .

Elbow is rested until the acute symptoms subside – at first in splint and positioned at 90 degree of flexsion and mid-rotation , later applying collar and cuff , movement is encouraged .

Late residual effect : ch .pain , or deformity by : arthroplasty or arthrodesis .

TB OF THE WRISTRarely .

Pain and stiffness icreased gradually .

Hand feels weak .

forearm looks wasted .

Wrist is swollen and warm , involvement of flexor tendon compartment ,lead to rise to large fluctuant swelling that crosses wrist into the palm [compound palmar ganglion ]

Sinus [neglected cases ] .

Mov .are restricted and painful .

followX-ray :

Localized osteoporosis

Irregularity of radio-carpal and intercarpal joint .

Bone erosion (sometimes) .

Diagnosis :

1-Should be D .Dx with RA .

TB: one wrist is affected .

RA : Bilateral

2- x-ray .

3- serological .

4- biopsy :necessary .

TTT : - ANTI –TB DRUG + wrist is splinted .

If there abscess : drainage .

If wrist destroyed :systemic ttt should be continued until diz .is quiescent and then arthrodesed .

TB OF THE HIP Start as synovitis or as osteomyelitis .

Artheritis develop occurs rapid destruction and pathological dislocation .

Healing usually leaves fibrous ankylosis with considerible limb shortening and deformity .

Clinical featurs:

Start insidiously with aching in groin , thigh and slight limp .

Later : sever pain and may wake the pt from sleep .

FOLLOW Early diz . : (synovitis or osteomyelitis ) the joint

is held flexed and abducted .

Exterme of movement are restricted and painful (difficult diagnosis) .

If artheritis supervenes:

- the hip becomes flexed adducted and medially rotated , obovious muscl wasting .

All mov .are grossly limited by pain and spasm .

ossly

FollowX-RAY

Early changes:

General rarefaction but with normal joint space and outline .

Femoral epiphysis may be enlarged or bone abscess visible .

In artheritis :

General rarefaction + destruction of acetabular roof (wandering acetabulum) 0r femoral head and usually both .

The joint may be subluxed or even dislocated .

FOLLOWHealing : the bone recalcify .

If treated early : leaving normal or almost normal hip .

Once the articular surface is destroyed unsound fibrous joint .

Untreated cases : leg become scarred and thin , sever shortening (because bone destruction , adduction and flexion deformity of the hip .

In children:

Damage to upper femoral epiphysis and occasionally premature fusion of lower femoral epiphysis .

TTTANTI TB DRUG

Skin traction-is applied .

For children : abduction frame .

Abscess in femoral neck : evacuated .

Artheritis does not settle : joint debridement .

If diz . Subside : traction is discontinue and movement is encouraged .

Follow If joint destroyed : arthrodesis usually not

before the age of 14 yrs .

In older pt with residual pain and deformity :

total joint replacement

TB OF KNEE May appear in any age ,but more common on

children then adult .

c\p:

Early pain , limp .

Swollen joint

Wasted muscle of thigh .

Mov . Restricted – painful .

Investigation :Mantoux test : positive .

ESR : increase .

X-ray :” osteoporosis

- enlarge bony epiphysis (children )

In late stage : joint surfaces are eroded .

DIAGNOSIS :

Mono-articular rheumatoid synovitis or juvenile ch . Artheritis ( D.Dx)

Synovial biopsy.

TTTGeneral ANTI-TB chemotherapy for 6-9 month .

In active stage :

knee is rested in bed splint ,(subside synovitis) , but if no :” after few wks . Surgical debridement .

In healing stage :

wearing wt – relieving caliper .gradually left off , but pt kept under observation ; for any sign of recurrent inflam.

If articular surface destroyed , immobilization is continued until the joint stiffness .

***In the after math :

joint may be painful ;it is then arthrodesed.

but in children usually postponed until growth is almost completed .

The ideal positon for fusion is 15 degree of flexion and 7 degree of valgus .

Sometimes joint replacement feasible .

TB OF THE ANKLE Start as synovitis or as osteomelitis .

Present befor true artheritises superven ; because walking is painfiul .

Ankle swollen and marked calf wasted .

Feel :

-skin warm .

-mov. Restricted .

- snius formation .(EARLY )

FOLLOW X-RAY :

RAREFACTION .

Sometimes bone abscess .

-with late disease : narrowing and irregularity joinrt space .

TTT:

ANTI-TB DRUG + Removable splint ; used to rest the foot

Arthrodesis in stiffness of artheritis .

How long for?

MANAGEMENT

Joint TB - managementUsually 6 months is standard

No controlled trials for peripheral joint TB

6 months?

12 months?

Do they require surgery?

Joint TB - managementHowever, if treatment is delayed, there can be considerable

loss of function and a requirement for extensive surgical intervention.

TherapyMedical therapy usually sufficient

Surgery in selected cases (cord compression, progressive neurology, marked kyphosis)

6(-9) months therapy 2HRZE+ 4HR

Indications for surgery patients aged less than 15 years, in whom the

initial angle of kyphosis is more than 30º

patients started on ambulant chemotherapy who develop progressive kyphosis

Indications for surgery children aged less than ten years with

destruction of vertebral bodies who have partial or no fusion even during programme

patients with compression of the spinal cord in whom the neurological status deteriorates in spite of chemotherapy

Key messagesPeripheral joint tuberculosis should be considered

in any patient with chronic joint pain

and particularly if there is swelling present

and especially if the patient is from an ethnic group with a high background incidence of tuberculosis.

Biopsy and culture is important to identify MDR-TB

Chemotherapy is sufficient in many cases and surgery is helpful in selected cases

^^ Many Thanx ^^