1、Skeletal Tuberculosis (Part-2)Dr. Sunil AroraJunior ResidentDeptt. of Chest &TBGovt. Medical College, Patiala.,1,1,Introduction,Skeletal TB accounts for 10 to 35% of cases of extrapulmonary tuberculosis. Although spine is the commonest site (constituting about 50%) of skeletal TB. The other bones an
2、d joints can also be involved. Skeletal TB generally occurs due to haematogenous spread from a primary focus.,2,Classification,TUBERCULAR ARTHRITIS- 30%HIP JOINTKNEEWRIST JOINTSACROILIAC JOINT ANKLE JOINT AND FOOTSHOULDER JOINT TUBERCULAR OSTEOMYELITIS- 19%LONG TUBULAR BONESSHORT TUBULAR BONESFLAT B
3、ONES- RIBS,STERNUM, SCAPULA, PELVIS TENOSYNOVITIS/BURSITIS- 1%,3,Pathogenesis,It produces similar response as in lungs i.e. Chronic granulomatous inflammation.The disease process can start either in bone or in the synovial membrane. Active focus forms in the metaphysis (in children) or epiphysis (in
4、 adults) and the inflammation extends peripherally along the shaft to reach the subperiosteal space. The inflammatory exudate may extend outward through the soft tissue to form cold abscess and sinuses.The affected bone may undergo fracture.,4,Metaphyseal infection reaches the joint through subperio
5、steal space by penetrating the capsular attachment.In adults,the inflammation can spread up to the subchondral area and enter the joint at the periphery where synovium joins the cartilage which leads to the loosening the attachment of articular cartilage and joint displacement.,5,Sometimes the synov
6、ium is infected first and the bone is infected secondarily.It is usually in the form of low-grade synovitis with thickening of the synovial membrane and leading to the formation of pannus.Eventually,the articular cartilage is destroyed,joint gets distended with pus,which may burst out to form a cold
7、 abscess or discharging sinus.The joint may also get subluxated due to the laxity of the joint capsule and ligaments. Fibrous ankylosis is a common outcome of healed tuberculosis of the joints except in spine where bony ankylosis follows more often.,6,Types,Two classical forms of disease have been s
8、een;granular and and exudative(caseous) that involve the bone and synovium.Both the patterns have been observed in patients of skeletal TB,one form may predominate. 1.Osseous granular type :-often follows trauma-insidious onset,constitutional symptoms rare,-soft tissue are slightly warm and tender-h
9、ealing without residual joint scarring&ankylosis2. Osseous exudative(caseous) type:-rapid onset,constitutional symptoms,muscle pain and spasm more marked-soft tissue are warm,swollen and tender-caseous material penetrates into jointdestructive arthritis-healing by joint scarring&ankylosis,7,Clinical
10、 Features,TB should be included in the differential diagnosis of any slow onset of disease of musculo-skeletal system particularly in TB prevalent countries like India.Symptoms can be:-Constitutional symptoms: The patient may be apathetic and pale Loss of weight and appetite Low grade fever(especial
11、ly in the afternoons) Night sweats,tachycardiaThese constitutional symptoms may be present before the definite symptoms pertaining to specific bone/joint involved.,8,Local clinical features These are specific to the site involved. But generally:- Pain Swelling (may be due to cold abscess) Night crie
12、s (in children due to rubbing of the two surfaces on movements during sleep after muscle relaxation) Painful limitation of movements Muscle wasting Sinus formation Deformities (in later stages)Patient may give a fallacious history of trauma which might have drawn the attention to a pre-existing lesi
13、on or activated a latent tubercular focus.,9,Investigation,Radiological Examination- Findings in early stages may be minimal and likely to be missed.A comparison with identical x-ray of opposite limb may be helpful. Localized osteoporosis is the first radiological sign of active disease.The articula
14、r margins become indefinite with areas of destruction,osteolysis and marked peri-articular rarefaction along with reduction in joint space. The synovial fluid,synovium and capsule may cause a soft tissue swelling. In advanced stages-subluxation,dislocation and deformity of the joint. Chest X-ray-to
15、detect any tubercular lesion in the lungs. MRI scan and Bone scan are useful in early diagnosis.,10,Other investigations,Haemogram It may show anemia, lymphocytic leucocytosis,high ESR Mx test useful in children. Synovial fluid aspiration -ADA Levels(Non TB septic arthritis patients have been report
16、edly higher than other types of inflammatory arthritis but not as high as TB arthritis).- Culture. Aspiration of cold abscess- Histopathological examination,Smear for AFB & culture. Biopsy- in doubtful diagnosis,may be from synovium,bone. FNAC from lymph node,11,Treatment,Aim of the treatment is to-
17、1. Control of the infection &2. Care of the diseased partIn most cases conservative treatment is sufficient,but sometimes operative interventions are required.Conservative treatment- ATT-As per RNTCP guidelines all Extra pulmonary new TB cases are to be given Cat-1.Which includes:-Intensive phase -
18、2 months which includes Rifampicin(450mg),Isoniazid(600mg),Ethambutol(1200mg) &Pyrazinamide(1500mg) Continuation phase 4 months of Isoniazid and Rifampicini.e.regimen is 2H3R3Z3E3+4H3R3 & continuation phase shall be extended by 3 months making the total duration of treatment to a total of 9 months f
19、or osteo-articular TB. Anti-inflammatory,pain killer&antipyretics (as and when required),12,Drainage of cold abscess should be done without delay to avoid sinus formation(by anti-gravity technique). Antibiotic for secondary infection(for persistently draining sinus which gets secondary infections).
20、Bed sore care and treat other comorbid condition.Building up of patients resistance High protein diet.Excision of sinus tract - if sinus are persisting.,13,Rest and braceAffected part should be rested during active stage of the disease.In upper limbs this can be done with the help of plaster slab an
21、d in lower limbs traction can be applied. As the disease comes under control and the pain reduces,joint mobilization is begun.Gradual mobilization should be encouraged with the help of suitable braces/appliances after 3-6 months of start of treatment when the healing is progressing, which are gradua
22、lly discarded after about 2 years. Exercise is started as the joint regains movement and weight bearing started gradually as osteoporosis secondary to disease is reversed In presence of gross destruction especially in weight bearing joints, immobilization may be continued to obtain sound ankylosis.,
23、14,Surgery in Skeletal TB,It is an adjunct to the anti-tubercular therapy,not a substitute.Following surgical procedures are employed for specific indications:-1. Excision of osseous focus threatening the integrity of neighbouring joint.2.Excision of entire/part of bone with evidence of gross destru
24、ction.3.Synovectomy in synovial TB,not responding to conservative treatment.4. Osteotomy to correct deformity when the joint has healed in a bad position5. Arthrodesis to obtain a sound ankylosis in advanced disease(knee,hip, ankle,wrist)6. Salvage operations are the procedures to perform in markedl
25、y destroyed joints in order to salvage whatever useful functions are possible.( e.g.Girdlestone arthroplsty),15,Tuberculosis of Hip,It occurs in about 15% of all cases of osteoarticular TB. It almost always start in bone and initial focus is in the :- 1. Acetabulum roof 2. Femoral epiphysis 3. Proxi
26、mal femoral metaphysis 4. Greater trochanter 5. Synovial membrane(rare) & disease may remain as synovitis for a few months.Since the head and neck of femur are intracapsular, a bony lesion here invades the joint early & later spread to involve the acetabulum . When disease starts in the acetabulum ,
27、 symptoms related to joint involvement appears late.Multiple cavitations occurs in femoral head and acetabulum.,16,Stages of TB of Hip,Classical untreated TB of hip passes through following 3 stages Stage 1 (stage of synovitis) Intrasynovial effusion and exudate distending the joint capsule demandin
28、g the hip to be in a position of maximum capacity i.e. position of flexion, abduction &external rotation. As the pelvis tilts to compensate for abduction and flexion deformities so the affected limb appears longer. This is a stage of apparent lengthening. Stage 2 (stage of Arthritis)- The capsule an
29、d articular cartilage is involved leading to spasm of powerful muscle. The hip joint assumes a position of flexion, adduction & internal rotation. The flexion & adduction may be concealed by compensatory tilt, the affected limb appears shorter i.e. stage of apparent shortening. Stage 3 (stage of Ero
30、sion)-The capsule is further destroyed, along with advanced destruction of cartilage and the head and/or acetabulum is eroded. The attitude of limb is flexion , adduction and internal rotation.There is true shortening of the limb because of the actual destruction of bone.The destroyed head may come
31、to lie proximally and posteriorlyWandering acetabulum or instead protrusio acetabuli can develop with destruction of medial wall of acetabulum,17,EXAMINATION,It should be carried out with the patient undressed. Gait Lameness is one of the first sign. In the early stage, it is because of the stiffnes
32、s and deformity of the hip. Because of the flexion deformity, patient stands with compensatory exaggerated lumbar lordosis.Later, the limp is exaggerated by pain, so that,the patient hastens to take the weight of the affected side(painful or antalgic gait). Muscle wasting of thigh and gluteal muscle
33、s. Swelling due to cold abscess-Sometimes joint space is filled with caseous material and it may track down to the path of least resistance resulting in cold abscesses in:-1.Inguinal region 2.Femoral triangle 3.ischiorectal fossa4.Adductor compartment of thigh 5. Greater trochanter,18,Discharging si
34、nuses in the groin or around the greater trochanter. There may be puckered scars from healed sinuses. Deformity Minimal deformities are compensated by pelvic tilt. Commonly it is flexion, adduction & internal rotation. Shortening Generally true shortening except in stage 1 ( which is apparent length
35、ening ). Movements Limitations of active and passive movements in all directions. If no movement at al ( Bony ankylosis ) Abnormal positioning of head-In a dislocated hip,head can be felt in gluteal region.,19,Investigation,1.Radiological Examination-X-rays AP &lateral view. 2.Other investigations-I
36、ncludes blood investigation,Mx,Synovial fluid examination, biopsy. MRI scan and Bone scan are useful in early diagnosis,20,21,Soft tissue swelling, osteoporosis, and loss of bone definition, as can be seen by comparison with the normal left hip,22,23,Radiological Types,Seven different types of radio
37、logical appearances in advance stage of TB hip joint are as:- Normal type Disease is mainly synovial, may be cysts in femoral neck, head or acetabulum, but no gross destruction and joint space is normal. Perthes type Generally seen under 5 years of age,Femoral head is sclerotic and it is difficult t
38、o differentiate from Perthes disease. Dislocating type Subluxation or dislocation of femoral head occurs due to capsular laxity and synovial hypertrophy(not due to accumulation of pus). Wandering acetabulum-There occurs destruction of acetabulum of its superior (weight bearing part)&femoral head shi
39、fts proximally on the ilium. Atrophic type Femoral head is irregular and joint space is narrow.Seen exclusively in adults. Protrusioacetabuli-medialization of the medial wall of the acetabulum. Mortar and Pastle type Destruction causes enlargement and deepening of acetabulum and femoral head shifts
40、medially,24,NORMAL TYPE,Radiograph of a 3-year-old girl with the normal type of tuberculosis of the right hip showing osteopenia and acetabular cysts.,25,PERTHES TYPE,Left femoral epiphysis is flattened absence of metaphyseal changes and presence of juxta-articular osteopenia favour TB over perthes
41、disease.,26,DISLOCATING TYPE,Rt Femur head gets dislocated due to capsular laxity and synovial hypertrophy rather than pus accumulation as in pyogenic arthiritis.,27,WANDERING ACETABULUM- The upper part of femur displace upwards and dorsally leaving lower part of acetabulum empty.,28,ATROPHIC TYPE,R
42、adiograph demonstrates complete joint destruction in the right hip, along with associated soft-tissue swelling and calcification.,29,MORTAR AND PESTLE TYPE : femoral head and neck are grossly destroyed, collapsed and contained in a large acetabulum,30,Differential Diagnosis,TB of hip is the commones
43、t cause of pain in the hip in children in TB prevalent countries.The following differential diagnosis should be considered: a) Rheumatoid arthritis- In rheumatoid arthritis B/L symmetrical, more small joint involvement,h/o remissions &the joint space is uniformly reduced, Inguinal LAN or Psoas Absce
44、ss Patients with these extra articular diseases often present with the flexion deformity of hip because of spasm of iliopsoas. All movements of the hip expect extension are pain free. Pyogenic arthritis- It can be differentiated as:-,31,32,d) Congenital dislocation of hip Limp is painless, generally
45、 detected at birth. Telescopy test is positive and X-ray are decisive. e) Congenital coxavara Painless limp, abduction and internal rotation are limited.Adduction and external rotation maybe increased. X-ray usually confirms the diagnosis. f) Perthes Disease Seen in age group of 5-10 years, associat
46、ed with minimal limitation of movements,mainly abduction and internal rotation. Typical X-ray changes are out of proportions to the physical findings. The joint space may be widened (unlike TB). Absence of metaphyseal changes and presence of juxta articular osteopenia favours TB g) Osteoarthritis oc
47、curs in older individuals.- Hip movements are limited in all directions but only terminally . - Associated pain and crepitus . h) PVNS - lack of osteopenia,heavy hemosiderin deposits causes prominent hypointensity on MRI,33,Treatment,In early stages- Conservative treatment-which includes ATT General
48、 care Care of hip- The affected hip is put to rest by immobilisation using below knee skin traction.In stage (i & ii) traction upto 12 weeks maybe required. It should be continued till disease activity is well controlled, hip movements improve and become pain free and muscle spasm does not occur.Gen
49、tle hip mobilisation and sitting in bed for short period are started during the period of traction. For the next 12 weeks, non weight bearing walking is allowed with crutches followed by another 12 week period of partial weight bearing. Unprotected weight bearing should not be permitted early to avoid collapse and deformity. In stage 2- Partial synovectomy and curettage of osteolytic lesions along with grafting. In stage 3- aim is to achieve fibrous ankylosis in a functional position.,34,Operative Management,
