For UnderGraduates and Orthopaedicians

1. Tuberculosis Of
Appendicular Skeleton
Dr. Apoorv Jain
D’Ortho, DNB Ortho
drapoorvjain23@gmail.com
+91-9845669975

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. Tuberculosis
Pulmonary
(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)
 Tuberculosis of tendon sheath and bursae

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

9. Tuberculosis Of
Hip Joint

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.

11. Ligaments around hip joint

12.  2nd most common osteoarticular
TB (next only to spinal TB)
 Commoner in males
INTRODUCTION:
PATHOGENESIS: • 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
Lesions of
acetabululum(roof)
Jnt involvement is
late & by the time
patient presents
Extensive bone
destruction already
present

17. Inferior part of Capsule(weak)
Femoral triangle, medial ,lateral
& posterior aspect of thigh
Pelvis
Above levator ani
Inguinal region
Below levator ani
Ischiorectal fossa
Tracking of abcess away from the joint is usually along
the Neuro-vascular bundle

24. As the disease
progress,
Head of femur partly
absorbed & gets
dislocated from
acetabulum onto
ilium
“WANDERING
ACETABULUM”

25. If left untreated,
Healing by absorption & connective tissue
encapsulation occurs.
Leading to distortion, deformity and fibrous
ankylosis of joint

27. Symptoms: (when disease is active)
 Constitutional symptoms
 Pain (absent in early stage, night cries/starting
pain)
 Limp (earliest, commonest, antalgic gait, asso.
stiffness)
 Deformity of limb (stage of involvement)
 Fullness around hip (site of cold abcess)

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, scoliosis etc))

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. Investigations:
 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 view.

34.  Biopsy and histopathological examination :
smear, culture and guinea pig inoculation.
Culture – 8 wks and only positive in 30-60% case.
Likelihood of identifying organism on a smear is
10-30%.
 C-reactive protein – prognosis factor
 MRI : effusion, periarticular osteoporosis,
thickening of synovial membrane.
 PCR : DNA based PCR can be quite sensitive, it
may not distinguish between viable and non-
viable bacilli. Messenger RNA based reversed
transcription PCR may be more specific

35.  To obtain a:
Painless, symptom free
Stable
Freely mobile joint
with the patient having a normal gait
without limp, deformity or shortening.

36. With the advent of modern chemotherapeutic
agents the intervention at early stages with
combination of surgical management
determines the prognosis
 Before irreversible change have taken place in
cartilage a good result can be expected from
conservative management.
 When head is affected the result is always
doubtful and if there is much bone destruction
ankylosis in a good position is the limit of cure.

37. General treatment :
 Liberal diet, fresh air, sunshine, education and
occupation.
Chemotherapy (ATT) :
 Chemotherapy forms the basis of treatment in all cases
and must be started immediately once the diagnosis is
made.
 The problem lies in deciding upon appropriate duration
of chemotherapy.
 Prevailing practice of extending treatment till radiological
evidence of healing in complete, may be unnecessary

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)

39.  First line essential drugs (most effective and necessary
component of therapeutic regimen) : Rifampicin,
Isoniazid and Pyrazinamide
 First line supplemental drugs (highly effective and
infrequently toxic) : Ethambutol, Streptomycin,
Fluoroquinolines – Cipro and Levofloxacin.
 Second line (less effective and elicit severe reaction more
frequently) : PAS, Ethionamide, Cycloserine, Amikacin
and Capreomycin.
 Newer drugs: Rifapentine, Gatifloxacin and Moxifloxacin

42. Drug 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 Stop drug
Hepatitis 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 Hepatitis 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
drug and get ophthalmologic
evaluation.
Streptomycin,
Amikacin,
Capreomycin
Ototoxicity,
Renal toxicity
Limit dose and duration of therapy as
much as possible. Monitor BUN and
serum creatinine levels and conduct
audiometry as needed

44.  Definition: Resistance to both INH and Rifampicin, with
or without resistance to any other AT drugs.
 Suspect MDR-TB if disease activity does not show signs
of subsiding after 4-6 months of uninterrupted
multidrug therapy.
 No standard regimes or guidelines. A regimen of 4 or 5
second line drugs including flouroquinolones is advised
& if needed, these drugs should be changed at sometime.
 Treatment, with these drugs takes 2 yr or longer, as
opposed to 6-9 months with INH rifampicin containing
regimen. 2nd line drugs more expensive & toxic initial
part of the treatment should be supervised in hospital.

45. a) Stages of synovitis and early arthritis
 ATT (multidrug therapy)
 Traction
 Palpable cold abscess may be aspirated with
instillation of streptomycin with or without
isoniazid.
 Active assisted movements of hip started as soon
as pain has subsided.
 Hip mobilization exercises every hour (when
patient is awake) within limits of tolerable pain.

46.  With traction : patient progressively encouraged to
sit, touch his forehead, sitting in squatting position
and putting thigh in abduction and external rotation.
 After 4-6 months patient is permitted for
ambulation with suitable caliper and crutches.
 12 wk non weight bearing, followed by
 12 wk partial weight bearing
 Nearly 12 months after onset of treatment –
crutches / caliper discarded.
 Unprotected weight bearing – usually 18-24 months
later.
 If response to conservative treatment is
unfavourable, synovectomy and debridement of
joint performed.

47.  Usual outcome is gross fibrosis ankylosis.
 Traction and exercises help to overcome the
deformities.
 Once gross ankylosis is anticipated of accepted limb
should be immobilized with help of plaster hip spica
for about 6-9 months.
 Ideal position in adults is neutral between
abduction and adduction; 5-10 degree of external
rotation and flexion depending upon age (between
10 degree in children and 30 degree in adult).
 After 6 month partial weight bearing is started and
later with crutches / with caliper for 2 years.

48.  Indications
 To establish diagnosis by obtaining tissue culture
 Surgery as a therapeutic measure
Joint debridement and clearance in
moderately involved cases.
Excision arthroplasty or arthrodesis
Very rarely total hip replacement.
 If response to non-operative treatment is
unfavourable, then go for synovectomy or
debridement.

49.  The deformity and subluxation / dislocation is
corrected or minimized by employing traction or
with plaster under G.A. with or without adductor
tenotomy.
 Failure to achieve correction of gross deformities and
minimization of subluxation / dislocation warrants
open arthrotomy, synovectomy and debridement of
the joint.
 Arthrodesis / excisional arthroplasty differed till
completion of growth potential. Disease with gross
deformity require an extra articular corrective
osteotomy to make them walk better till skeletal
maturity

50.  Hypertropied synovium from inner surface of
capsule and from synovial reflections near
the acetabular rim and femoral neck are
separated.
 Diseased and thickened capsule is excised.
 Diseased synovium from the retinacular
relfextions on femoral head gently curreted.
 Appropriate rotations of hip joint permit
adequate synovectomy from deeper parts of
hip joint without deliberately dislocating hip
joint.

51. In addition to synovectomy,
Remove
 the destroyed areas of femoral head & neck and
in the acetabulum.
 Loosened pieces of articular cartilage, sequestra,
granulation tissue and loose bodies / debris
within the joint
 The diseased thickened capsule
(Synovectomy and joint debridement can be
satisfactorily carried out without dislocating the
hip joint. IR and ER provide access to deeper
parts of joint cavity)

52. 1) Avascular Necrosis
2) Slippage of proximal femoral epiphysis in
children.
3) Fracture of femoral neck or acetabulum.

53.  Sound ankylosis in bad position requires upper
femoral corrective osteotomy.
 Sometimes unsound (fibrous painful) ankylosis
in bad position becomes an osseous fusion
(sound painless) by a high femoral corrective
osteotomy.
 This extra articular procedure can be done at any
age.
 Ideal site for corrective osteotomy is as near the
deformed joint as possible.

54.  Success of chemotherapy has almost eliminated the
absolute indications for surgical fusion of hip joint.
 Surgery deferred till the growth potential of proximal
femur has been completed.
 Consider in cases of
 Failure of conservative treatment (after 1 year)
 Relapse, especially recurrence of pain and deformity after
conservative treatment.
 Certain destruction lesions. Ex : formation of sequestra in
head or neck of femur or acetabulum.

55. Problems encountered :
 Early development of degenerative osteoarthritis
in lumbosacral spine, ipsilateral knee and
contralateral hip.
 Compensatory mechanisms for fused hip
Increased rotation of pelvis (during sitting and
walking)
 Activities affected – bending, sitting on floor,
cross legged sitting, squattering, kneeling, sports,
sexual mechanisms (in women) and bicycling.

56. Types :
• Intraarticular
• Extraarticular (ischio-femoral and
ilio-femoral)
• Combined (pan articular)
Arthrodesis

57.  Best position of Arthrodesis:
 300of flexion (depending upon age)
 No abduction or adduction (in adults)
 5 to 100 of external rotation
 (the position of flexion – 10 for each year of
life upto 200 then, a little more is suggested)
 Extended hip – comfortable for walking
 Flexed hip – comfortable for sitting
This surgery best suited for young active people and for
manual labourer

58. Performed if disease is active, painful fibrous
ankylosis is present
Permits
- To obtain tissue for HPE
- Exploration of joint
- Excision of diseased tissues
- Curettage of juxta articular infected cavities
- Supplementation of bone grafts to obtain
fusion.

59. Procedure :
Standard anterolateral approach, dislocate joint carefully,
Excise cartilage and subchondral bone from femoral head
and acetabulum,curet juxta articular cavities, large ones fill
up with cancellous bone grafts repose head into
acetabulum, place cancellous bone graft around joint line.
Approximate capsule and soft tissue over the site of fusion
Hold hip in functional position, 2-3 Steinmen’s pins passed
from base of greater trochanter to neck, head and into the
acetabulum.
Close wound over suction drain, single hip spica applied.
Post op regime :
Steinmen pin removal after 6 to 8 wks
Single hip spica applied in desired position
Gradual weight bearing with crutches for 4 to 6 months until radiological
E/o bone fusion.

60. EXTRA ARTICULAR FUSION
(BRITTAIN’S TECHNIQUE / ISCHIO-FEMORAL
ARTHRODESIS)
BRITTAIN’S

61. Indications :
 Extensive destruction of head and neck of femur.
 Deficient bone stock due to prior arthroplasty.
 Patients life style prefers a strong, fused and
painless hip joint.
 Can be done in the presence of active infection or
draining sinuses.

62.  Involves excision of femoral head, neck, proximal
part of trochanter and acetabular rim.
 Best suited for Indian subcontinent people,
whose essential activities are squatting, sitting
crosslegged and kneeling.
 Safely done in healed / active disease after
completion of growth potential.
 Provides painless, mobile hip joint with control
of infection and correction of deformity.

63.  Upper tibial skeletal traction, mounted in 300-500
abduction for 3 months.
 Encouraged to sit soon after surgery and active
assisted movements of hip and knee started
during first week.
 Encouraged to place limb in tailor’s position and
squatting posture.
 After 3 months – mobilization with caliper /
crutches.
 After 6-9 months – they are discarded and to use
walking stick on the contralateral hand.

64. Soon after surgery 5 years later

66.  Excision arthroplasty can rarely have a very
unstable hip joint. If happen in young patient, it
need supplementary operation.
 Hip stabilization procedure
 Pelvic support osteotomy (Milch- Bacheolar type) at
the level of ischeal tuberosity.
 Supra acetabular shelf : full thickness iliac crest is used
to provide shelf at upper margin of acetabulum, to
minimize upward excursion of femur on weight
bearing.
 An interesting technique of interposition
arthroplasty employing multilayered amniotic
membrane – reported by Vishwakarma (1986).

67.  Low friction arthroplasty.
 Role of THR is being debated and
performed in highly selected cases.
 Most authors suggest this operation at
least 10 yrs after last E/o active
infection / drainage and under cover of
ATT. Despite precaution, reactivation
rate is 10-30%

69. Tuberculosis Of
Knee Joint

70.  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.

71.  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)

72.  Periarticular
osteopenia
 Erosions
 Symmetric
reduction of joint
space

73.  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

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

75. • Marrow edema
• Synovial
thickening
T2

76. Differential diagnosis –
 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

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

79.  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

80.  Can be prevented by adequate posturing
and Bracing in initial affection of joint
 Treatment of Triple Deformity of Knee in
TB:
 Double Traction (90-90): For Supple
deformities
 Anti- tubercular Therapy

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

82. Tuberculosis Of
Shoulder Joint

83.  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.

84.  Iatrogenic due to steroid injection given for
a stiff shoulder with the mistaken diagnosis
of frozen shoulder, particularly in diabetics.
 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 rotation
 gross wasting of shoulder muscles

85.  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
 Fibrous ankylosis

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

87. • Erosion
• Synovial proliferation
• Subdeltoid collection

88. Caries sicca:
 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

89. 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.

90.  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.

91. Tubercular
Dactylitis

92.  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

94.  Monostotic involvement is common
 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 with air

95.  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 lesions
in the foot

96. Tuberculous
dactylitis

97. Spina ventosa

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

99. 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

101. 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

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

103. Button sequestrum

104.  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

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

106. Tuberculosis is a major public health
problem in most of the world.
“Before the disease can be treated, it must
be recognized and before it can be
recognized, it must be considered a
diagnostic possibility”.

107. Thank You!