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tuberculosis of bone and joint/SKN-06

Tuberculosis of Bone and Joint


I P. Sukarna
History of Bone ad Jonit Tuberculosis
I. First period : Dark ages
1882
Percival Pott : kind of palsy of the lower lims which is fre!"ently fo"nd to
accompany a c"rvat"re of the spine#. $"t the aetiology was not known
II. %econd period : &"ercle $acil"s 'ra
1882 : (oert )och *in $erlin+ : tc ca"sed y microorg : $acill"s
&"erc"losis.
*1,81-182.+ : /aenec 0 inventor of stethoscope : microscopic lesion :
t"ercle# . 1e died at 223 fell prey to t disease
no dr"gs against t
focal s"rgery3 s"rgical iopsy
&4 : rest3 s"nshine3 general condition
III. &hird period : 5an6s tri"mph
1728 9aksman : streptomycin active against t acil
no focal s"rgery done any more
178:-17.: : t one ; <oints &4 : chemotherapy3 s"rgery : selective
I=. Fo"rth period : >lorio"s f"t"re
Ind"strial co"ntries : t-rare
Developing co"ntries : t-still many
>eneral prevention
&he mortality efore era chemotherapy : ,2.8?
after : *21.1?-8.8?+
To-days problem
1. Diagnostic
In ind"strial co"ntries : D4 is di@c"lt rarity
In developing co"ntries :
o D4 : not so di@c"lt
o common disease
o often with complication
o gross deformity
2. Dr"g resistance in endemic areas
A. modallity of &4 : controversies :
o conservative
o operative
Natural history
Primary l"ng lesion

*Bld+ primary lesion *dormant in ad"lt+ lood stream one3


synovi"m
Cew primary lesion
Dhemotherapy treatment :
has changed the pathologic ; pathophysiologic co"rse of the disease
3 Stages : (total duration 3- years!
1
st
stage :
1
tuberculosis of bone and joint/SKN-06
synovial memrane
<"4ta 0 artic"lar one
synovial memrane : months or years
o thick3 edemato"s eE"sion
$one : weeks or months
o limited one destr"ction
o dif"se one decalciFcation *rarefaction+
$one-synovial order
o active process : one lesion : rat ite phenomena on 4-ray
2
nd
stage :
stage of destr"ction *one ; cartilage+3 <oint space : decrease
synovi"m : e4tensively aEected : hyperplastic
within caseo"s inside coalesce large mass 0 ascess *cold+
p"s e4tend to caps"leGligamentGone iologic and mechanical destr"ction of
the <oint
growth plate involved with its conse!"ences.
5"scle : wasting3 contract"re
Hoint deformity : ang"lation3 dislocation
*cold+ ascess Flled with case"m 0 spread -- dissecting m"scles3 fascia 0
r"pt"re *e4ternally+ often remote from initial process 0 sin"s
2
nd
ary pyogenic infection
cache4ia 0 dissemination 0 amyloid degeneration 0 die
A
rd
stage
stage of repair
occ"rs spontaneo"sly after *2-A+ years
general condition improves
healing in 2
th
year
o ony f"sion
o Fro"s stiEness *rec"rrent+
"hemotherapy
has changed the co"rse of one ; <oint t
1. arrest the destr"ction process
2. never repairs anatomical defects what is destroyed remains destroyed#
'arly stage : heals y resol"tion
/ate stage : heals y Fro"s or ony ankylosis
#pidemiology
Prevalence :
%osioeconomic ackgro"nd
%tandard of p"lic health
Incidence :
& ones ; <oints : 1.12? of the total t"erc"losis
& ones ; <oints : 8.8? of all e4trap"lmonary tc
& spine *8:-,:+?
1ip 18? with t of the l"ng I*A8-8:+? *5artini+
)nee 18?
2
Davidson3Fernandes
tuberculosis of bone and joint/SKN-06
Bthers 2:?
Tuberculosis $e%eloping countries $e%eloped& "ountries
Prevalent yes rare
Dlinically appear3 ma<or minor
(adiologic destr"ctive non-destr"ctive
Diagnosis easy di@c"lt
Brthopaedic prolem no
Domplication no
J s"rgery conservative
'athology
Brgan
& acil insemination
('%

P.5.C. cells
*ne"trophyl+
soon replaced y *28 hrs+
5acrophages *monon"clears+
Phagocytose t acil
&ransform into
'pithelioidcells n"mers f"sion giant cells *m"ltin"clear+
1 week later
s"rro"nded y lymphocyte cells
ring *corona+ mass I Cod"le
I hard &K$'(D/' grows y e4pansion and coalescence
2 weeks
caseation in the center
I soft &K$'(D/'
Tuberculosis
1ip <oint
)nee <oint
=ertera
Hoint *hip3 knee3 etc+
Primary lesion : l"ngs3 *mediastinal+ lymph nodes which is active3 !"iscient or
latent spreading : vasc"lar
&-acil infects
A
tuberculosis of bone and joint/SKN-06
o %ynovial tiss"e
o or s"chondral one same vasc"lariLation
o or oth
o >ran"loma
%ynovial e4"date pann"s cartilage n"trition destroy the
cartilage
%"chondral *synov.one <"nction+ detach the chondral
layer
o Dartilage lesion from periphery. '4"date : no proteolytic enLyme
*compare : s"pp"rative+
o Dentral 9.$. area preserve for many years *f"nction+
o $y eEective &4 : good f"nction
Infection in metaphysis :
o >rowth plate : has no arrier f"nction can e penetrated y the t
process <oint space
Mscess *cold+ spreads sin"s 0 2
nd
ary infection
%pine t
o the most common J .:?
o ma<or location : &8-/A
o least common : D1-D2
o 2 or A verterae may e involved
o 2 diEerent lesion may occ"r
o primary lesion : l"ngs3 lymphnodes *mediastinal3 mesentary3
cervical+3 kidney3 other viscera *active3 !"iscient3 apparent or latent+
o spreading :
vasc"lar :
arteri : acteriaemia
veins : ple4"s of $atson
lymphogen : anatomic levels F. : )idney t-/
direct
o A pattern of involvements :
1. central type : $atson6s ple4"s
2. paradiscal type : vasc"lar
A. anterior type : ascess e4tension
Spreading of the %ertebral abscess
5arked e4"date
reaction
2
Dold
ascess
corp"s
tuberculosis of bone and joint/SKN-06
paraverteral anterior
ascess posterio
interverteral disc
necrosis
n"trition
dist"red
%preading3 e4tention
prop"lsion3 retrop"lsion
y compression of 2 verterae
(uture course of tb spine
1. may resolve completely
2. the lesion walled oE3 caseo"s tiss"e calciFed
A. low grade chronic Fromato"s gran"lating ; caseating
2. local spreading or systemic spreading
1ealing
1. Firo"s healing gives widegap
2. $ony ankylosis :
in children
in ad"lt *after chemo &4 in given+
"omplication
1. ascess spreading
2. %coliosis
A. )yphosis
2. Paraplegia *spinal cord lesion+
)adiology
DlassiFcation *David-Dha"sse+3 17,7
%tage I
%ynovial onset :
o Co ony lesion
o DiE"se osteoporosis *rarefaction+
o Hoint space : widening J
%tage II
$ony onset :
o H"4ta artic"lar one : erosionGcavities
o Hoint space decrease
%tage III
9hole <oint involved
o Mnatomical appearance J C
o $ony cavities
8
Paradiscal
t-
process
longit.lig.
tuberculosis of bone and joint/SKN-06
o Hoint space disappear
o %evere demineraliLation
%tage I=
9orsening of all stage III
o >ross anatomical appearance is poor
o %tage III J I= : adly washed 4-ray# : severe osteoporosis and soft
tiss"e swelling interposition
o If necessary tomogram
*aboratory
no diagnostic val"e
'%(3 le"co3 lympho 0 no help in disting"ishing pyogenic or speciFc process
traditionally : '%(3 le"co : C3 P5C : C3 lymphocytes
%kin t"erc"lin test 7,? J
D"lt"re otained from
o $iopsy :
aspirationGneedle iopsy
arthroscopy
open
N-ray of the l"ng and "rine *t of &r.K>+ ro"tinely e4am.
Bacteriology
acid fast
scarcely in one ; <oint
strictly aeroic organism
o needs B
2
to m"ltiply Op"lmonary t : rich B
2
many acilsP
m"ltiplication :
o B
2
needed
o P1 ne"tral
dormant acteria
microscopic e4am J 11? *J+
2 diEerent acterial pop"lation
*5itchison ; Dicknison+ 17,8
*ung lesion Bone + Joint
*esions
,cti%e drugs
)-(.'/,
Dontino"s act
growth
Dontino"s act
growth
J
Intermittent Intermittent J
; slow growth act ; slow growth act J
Dormant act Dormant act Q
$iagnosis
1. PM : soft t"ercle : gran"loma J caseo"s
2. PM : hard t"ercle J clinical signs J (adiology
A. D"lt"re
1ard t"ercle : gran"loma witho"t caseo"s *noncaseating gran"loma+
.
tuberculosis of bone and joint/SKN-06
a. t"erc"loid leprosy
. cocydidiomycosis
c. atypical mycoateria
d. erythema nodos"m
e. tra"matic fat necrosis
f. r"cellosis
g. gran"loma ca"sed y contamination
- Lirconi"m
- erylli"m
- corp. Mlien"m giant cell reaction
- hydatic deris
- Drown6s disease
- sarcoidosis
0eneral 'rinciples of Treatment
>eneral3 chemotherapy3 local3 operative3 ascess
>eneral :
(est3 lieral diet3 hygienic s"rro"nding
"hemotherapy :
5ethod of choice3 most treatment
2 asic principles :
a. m"ltiple chemot43 sensitive to t-acil
. s"@cient period of time
&4 complience3 ma<or determant of &4. eEectivenes
%ome regiments
&raditional triple dr"gs
IC1G(IFGPR for 2 months
Dontin"ed IC1G(IF for *7-18+ months
%in"s *es+ present : road spectr"m antiiotic
Pyrido4in added to prevent to4ic eEect of IC1
or IC1G(IFGPR J ' or % for 2 months
Dontin"ed IC1G(IF for *7-18+ months
Dosis :
IsoniaLid *IC1+ : *1:-2:+mgGkg PB ma4 A::mgGday
(ifampicine *(IF+ : *1:-2:+mgGkg PB ma4 .::mgGday
PyraLinamide *PR+ : *18-A:+mgGkg PB ma4 2gGday
'tham"tol *'+ : *18-2:+mgGkg PB ma4 238gGday
%treptomycin *%+ : *2:-2:+mgGkg PB ma4 1gGday
*ocal T1
ImmoiliLation : plastering3 racing
5oiliLation : depend on the local condition3 to preserve cartilage3 (B53
m"scle tone
(ed"ction of deformity : traction3 plastering
(ehailitation
,
tuberculosis of bone and joint/SKN-06
2perati%e
Kmrella *1:-12+ days efore s"rgery
%hortened the d"ration of the desease
Dertain indications :
o e4tensive destr"ction of the process
o stage II3 *III+ clinically
o stage III3 *I=+ radiologically
o no or slow improvement y conservative &4
o large ascess
o cord compression
o kyphosis S A:
:
in children
Deridement3 synovectomy3 correct deformity3 preserve the >.P
,bscess
1. conservative
2. drainage : tension3 press"re
aspiration
incision
TB-3yphosis
Mng"lar deformity of spine
%erio"sness in children
Da"se :
o verteral ; disc damage
o Fro"s ankylosis
o d"ring healing process : s"<ected stress &h-&h-/ stress kyphosis
)yphosis in children : di@c"lt prolem
o may compromise visceral f"nction
cardio-respiratory prolem
paraplegia *internal gi"s+
o ad<acent spinal segments : compensatory hyperlordosis
o ri changes
o sternal deformity
o spontaneo"s posterior spinal f"sion
o may associated with paraplegia of healed desease with or witho"t
resid"al active disease
5edical (esarch Do"ncil in )orea *1788+
1.: children : &1 ; / kyphosis S 1:
:
at Frst e4am :
follow "p in 1: years3 increase in kyphosis
*1:
:
-A:
:
+ I AA ?
*A1
:
-8:
:
+ I 1,?
8
tuberculosis of bone and joint/SKN-06
*81
:
-,:
:
+ I.?
no change I A.?
decrease I 8?
ImmoiliLation does6nt arrest the anatomical damage
Degree of kyphosis depends on :
1. Initial kyphosis3 n"mer of verteral involved
2. location of kyphosis3 &h3 &h-/
A. age of onset
2. lack of ony f"sion
8. vasc"lar factor of growth plate
&reatment of kyphosis
'arly detection and treatment
SA:
:
radical s"rgery *1odgson+
J posterior arthrodesis
)eference
1. Mpley M>3 %olomon / : Mpley6s %ystem of Brthopaedics and Fract"res ,
th
'd
*p.2,-8:+. $"tterworth 1einemann3 177A
2. Davidson PF3 Fernendes ': $one and Hoint &"erc"losis3 %chlosserg D *'d+
%pringer 0=erlag3 $erlin3 1788
A. D"thie ($3 $ently > : 5ercer6s Brthopaedic %"rgery 7
th
'd *p..:2-.A2+
MrnoldGB4ford Kniversity Pres3 Cew Tork3 177.
2. 5artini3 5 : &"erc"losis of the $ones and Hoints. %pringer-=erlag3 $erlin3
1788
8. &ach<ian 5D. Pediatric Brthopaedics.2
nd
'd-=ol 2 *p.122A-12.1+3 $.$.
%a"nders3 177:
.. &"li % 5: &"erc"losis of the %pine. Mmerind P"l. Do. Cew Delhi3 17,8
7