Tuberculosis of joint Taiz University,faculty of medicine and health sciences By Dr : Monira Ahmed

1. 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.

2. Tuberculosis Diagnosis
l long history
l involvement of single joint
l marked thickening of the synovium
l marked muscle wasting
l periarticular osteoporosis
l +ve Mantoux test

3. l contact with TB
l pain, swelling, loss of weight
l joint swelling
l decrease ROM
l ankylosis
l deformity

4. Clinical features
Constitutional
symptoms
 Malaise
 Loss of
appetite/weight loss
 Night sweats .
 Night fever .
Specific features
 Stiffness
 Enlarged lymph
nodes
 Neurodeficit

7. Joint TB - Investigations
 Plain 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 biopsy
 ie tissue for TB culture should sent in saline or
water
 Higher yield2
1. Desai.J Bone Joint surg Br.1994
2. osteoarticular TB in a general hospital in the last decade.ruiz.clin microbiol infect.2003

8. Tuberculosis Investigation
l FBC , ESR,
l Mantoux
NOT IN:
MILIARY TB / RECENTLY VACCINATED/ ON STEROIDS / REDUCED IMMUNITY /
FEVER
l Xray -soft tissue swelling
-periarticular osteoporosis
-joint appear washed out
articular space narrowing
l Joint aspiration AAFB identified in 10-20%

9. Joint TB - Management
 Standard quadruple therapy*
 Rifampicin
 Isoniazid
 Pyrazinamide
 Ethambutol
*short course chemotherapy for spinal Tb.parthasarathy.
journal of bone and joint surgery.1999

10. Radiographic features
Plain film
 early stages (stage of synovitis and
arthritis)
• periarticular demineralisation(osteoporosis)
• joint space widening (due to joint effusion)
• mild subchondral erosion

11. 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)

12. Tuberculosis
differential diagnosis
l transient synovitis
l monoarticular RA .
l haemorhagic arthritis
l pyogenic arthritis

13. TB OF JOINT
 TB OF SHOULDER .
 TB OF ELBOW .
 TB OF WRIST .
 TB OF HIP .
 TB OF KNEE .
 TB OF ANKLE .

14. TB OF SHOULDER
 Uncommon .
 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 .

15. 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.

16. 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 .

17. 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

18. 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

19. follow
 Active 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

20. 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 .

21. TB OF THE WRIST
 Rarely .
 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 .

22. follow
 X-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

23.  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 .

24. 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 .

25. 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 .

26. Follow
X-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 .

27. FOLLOW
 Healing : 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 .

28. TTT
 ANTI 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 .

29. Follow
 If joint destroyed : arthrodesis usually not before the
age of 14 yrs .
 In older pt with residual pain and deformity :
 total joint replacement

30. TB OF KNEE
 May appear in any age ,but more common on children
then adult .
 cp:
 Early pain , limp .
 Swollen joint
 Wasted muscle of thigh .
 Mov . Restricted – painful .

31. 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.

32. TTT
General 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 .

33. ***
 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 .

34. 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 )

35. 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 .

36. How long for?
MANAGEMENT

37. Joint TB - management
 Usually 6 months is standard
 No controlled trials for peripheral joint TB
 6 months?
 12 months?
 Do they require surgery?

38. Joint TB - management
 However, if treatment is delayed, there can be considerable
loss of function and a requirement for extensive surgical
intervention.

39. Therapy
 Medical therapy usually sufficient
 Surgery in selected cases (cord compression,
progressive neurology, marked kyphosis)
 6(-9) months therapy
 2HRZE+ 4HR

40. 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

41. 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

42. Key messages
 Peripheral 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

43. ^^ Many Thanx ^^