TB KNEE.pptx

TB KNEE - MS ORTHO

1. TB KNEE DR. ISHDEEP SINGH OBEROI (PG-1) Department of Orthopedics, SMS&R

2. SKELETAL TB ACCOUNTS FOR 10 TO 35 PERCENT OF CASES OF EXTRAPULMONARY TUBERCULOSIS. AFTER LUNG AND LYMPH NODES,SKELETAL TB IS THE NEXT COMMON TYPE.IT CONSTITUTES ABOUT 1-4% OF TOTAL TB CASES.(MORE IN HIV-INFECTED PATIENTS) SKELETAL TB GENERALLY OCCURS DUE TO HEMATOGENOUS SPREAD FROM A PRIMARY FOCUS. COEXISTING PULMONARY TB IS SEEN IN APPR.50% CASES

3. KNEE: LARGEST JT IN THE BODY HAVING LARGEST INTRA-ARTICULAR SPACE 3RD MC SITE OF OSTEOARTICULAR TB 10% OF ALL SKELETAL TB LESIONS SPINE>HIP> KNEE

4. PATHOLOGY INITIAL FOCUS OCCURS BY HEMATOGENOUS DISSEMINATION IN THE SYNOVIUM JUXTA ARTICULAR OSSEOUS FOCUS IN THE SUBCHONDRAL BONE THE SYNOVIAL LESION MAY FOR MANY MONTHS REMAIN PURELY AS TUBERCULAR SYNOVITIS

5. SYNOVIAL MEMBRANE(SM) GETS CONGESTED, EDEMATOUS & STUDDED WITH TUBERCLES NAKED EYE EXAMN: PINKISH BLUE/GREY APP. SM BECOMES HYPERTROPHIED & THICKENED W GRANULATION TISSUE

6. JOINT FLUID IN INITIAL STAGES IS INCREASED, SEROUS, OPALESCENT, TURBID, YELLOWISH AND MAY CONTAIN FIBRINOUS FLAKES. IN ADVANCED STAGES, TUBERCULAR PROCESS BECOMES OSTEOARTICULAR, ERODES: ARTICULAR MARGINS, BONES, CRUCIATE LIGS, PERIARTICULAR TISSUE, CAPSULE.

7. INTRA-ARTICULAR RICE BODY FORMATION CAN OCCUR IN CHRONIC INFLAMMATORY DISEASES SUCH AS RA, TB ARTHRITIS, CHRONIC FUNGAL INFECTIONS, SYNOVIAL CHONDROMATOSIS, PIGMENTED VILLONODULAR SYNOVITIS, GOUT, OR SYSTEMIC LUPUS ERYTHEMATOSUS RICE BODIES ARE MAINLY FORMED OF FIBRIN AND ARE SEEN IN RELATION TO JOINTS, BURSA OR TENDON SHEATHS. RICE BODIES ARE NON-SPECIFIC FINDINGS IN CHRONIC INFLAMMATION THAT ARISE FROM MICROINFARCTIONS WITH SYNOVIAL SHEDDING ENCAPSULATED BY FIBRIN WHAT ARE RICE BODIES?

8. CLINICAL FEATURES ONSET/ COURSE : INSIDIOUS WITH USUAL SYSTEMIC & LOCAL FEATURES OF TUBERCULOUS DS SWELLING, FILLING UP ALL PARAPATELLAR FOSSA EARLIEST IN MEDIAL PARAPATELLAR FOSSA, SUPRAPATELLAR, POPLITEAL FOSSA. SWELLING : WARM, BOGGY/DOUGHY ( BEST PALPATED ON MEDIAL SIDE OF KNEE) PATELLAR TAP +VE IF SWELLING PREDOMINANTLY DUE TO SYNOVIAL EFF.

9. C/F CONTD. TENDERNESS MOST MARKED AT SYNOVIAL REFLECTIONS+ALONG JT LINE. IN SYNOVIAL DS, FOR A LONG TIME THERE MAYBE ONLY TERMINAL RESTRICTION OF MOVEMENTS. IN NEGLECTED CASES, DUE TO SPASM AND CONTRACTURE OF HAMSTRINGS ( B.F ) LEG PULLED INTO FLEXION, POST LAT SUBLUXATION, EXT ROT & ABDUCTION. ONCE SET IN, TFL THROUGH ITB FURTHER EXANTUATES. POST CAPSULE GETS CONTRACTED IN LONG STANDING CASES

10. DIAGNOSIS BLOOD : RELATIVE LYMPHOCYTOSIS, LOW HB, ↑↑ESR, ↓GLUCOSE, ↑PROTEIN MANTOUX TEST : +VE REACTION IS PRESENT IN A PT WITH TUBERCULOUS DS OF SOME STANDING (ONE TO 3 MONTHS), -VE TEST IN GENERAL RULES OUT THE DS. BIOPSY :EPITHELOID CELLS SURROUNDED BY LYMPHOCYTES IN THE CONFIGURATION OF A TUBERCLE(EVEN WITHOUT CENTRAL NECROSIS OR PERIPHERAL FOREIGN BODY GIANT CELLS) IS AN ADEQUATE HISTOLOGICAL EVIDENCE. GUINEA PIG INOCULATION : PUS INJECTED INTO THE ANIMAL INTRAPERITONEALLY, +VE IF TUBERCLES APPEAR IN 5-8WKS. UNECONOMICAL BUT PERHAPS MOST RELIABLE PROOF.

11. SMEAR & CULTURE : MAYBE SENT FOR AFB ( LOWENSTEIN JENSEN ) ISOTOPE SCINTIGRAPHY: COMMON IN AFFLUENT COUNTRIES, USES TC, GA, IN. TC IS EXTREMELY SENSITIVE BUT LACK OF SPECIFICITY, MAY SHOW INCREASED UPTAKE IN OSTEOPOROTIC #S,INFECTIONS,STRESS #, HEALING TRAUMATIC #S. SEROLOGY: ELISA FOR AB TO MYCOBACTERIAL AG -6, 94% SENSITIVITY, 100% SPECIFICITY. GENXPERT PCR : 95% SENSITIVITY, 96% SPECIFICITY. QUNTIFERON TB GOLD : 84% SENSITIVITY, 95% SPECIFICITY.

12. RADIOGRAPHIC FINDINGS XRAY :

13. TUBERCULAR ARTHROPATHY CAN BE DIVIDED ON THE BASIS OF RADIOLOGICAL FEATURES: 1. EARLY STAGES (STAGE OF SYNOVITIS AND ARTHRITIS) PERIARTICULAR DEMINERALIZATION JOINT SPACE WIDENING (JOINT EFFUSION) MILD SUBCHONDRAL EROSION 2. LATE STAGES (STAGE OF EROSION AND DESTRUCTION) GRADUAL NARROWING OF JT SPACE(INV OF ARTICULAR CARTILAGE) SEVERE SUBCHONDRAL EROSION AND DESTRUCTION PATHOLOGICAL SUBLUXATION AND DISLOCATION FIBROUS ANKYLOSIS ATROPHIC CHANGES IN BONES LEADING TO ATROPHIC ARTHROPATHY

14. ± KNEE VALGUS = QUADRUPLE DEFORMITY T - TUBERCULOSIS R -RA I -ITB CONTRACTURE P -POLIO L -LOW CLOTTING CAPACITY E -EXCESS BLEEDING/HEMOPHILIA

15. MODERN IMAGING TECHNIQUES CT SCANS : HELPFUL IN DEMONSTRATING LYTIC CAVITIES IN BONE AND MARGINAL EROSIONS BEFORE THESE CAN BE SEEN ON XRAYS. MRI : WOULD CONFIRM WHATEVER ONE CAN SEE IN PLAIN XRAYS & CT. ALSO SHOWS PRESDESTRUCTIVE LESIONS LIKE DEMINERALIZATION, EDEMA, INFLAMMATION OF THE BONE IN ACTIVE DISEASE. ROLE OF GADOLINIUM AS A CONTRAST MEDIUM IN MRI HAS NOT YET BEEN FULLY ESTABLISHED IN INFECTIVE LESIONS. USG : BEEN EMPLOYED BY VARIOUS WORKERS TO ESTIMATE THE PRESENCE OF SOFT TISSUE ABSCESSES AND ITS BEHAVIOUR UNDER TREATMENT.

16. PROGNOSIS USE OF ATT HAS REVOLUTIONIZED THE OUTCOME OF RX OF BONE & JT TUBERCULOSIS. DEATHS DUE TO UNCONTROLLED DS, MENINGITIS, MILIARY TB, AMYLOIDOSIS, PARALYSIS ARE NOW RARE. IF DIAGNOSED EARLY, TREATED VIGOROUSLY, HEALING CAN BE ACCOMPLISHED WITHOUT RESIDUAL ANKYLOSIS. I N THE STAGE OF SYNOVITIS , NON OPERATIVE ( OR OPERATIVE WHEN INDICATED) TREATMENT OFTEN RESULTS IN COMPLETE HEALING WITH AN EXCELLENT RANGE OF MOVEMENTS. IN ADVANCED ARTHRITIS WITH SUBLUXATION SEVERE RESTRICTION OF MOTION IS INEVITABLE, THEREFORE, ARTHRODESIS ( IN ADULTS ) IN FUNCTIONING POSITION ( 5-10 DEGREE OF FLEXION) IS ONE OF THE OPTIONS OF TREATMENT

17. TREATMENT NON-OPERATIVE RX WITH ANTITUBERCULAR DRUGS IS EMPLOYED IN TUBERCULAR SYNOVITIS AND IN CHILDREN.TRACTION IS APPLIED TO PREVENT( OR CORRECT) FLEXION AND SUBLUXATION DEFORMITY, AND TO KEEP THE JOINT SURFACES DISTRACTED. IN ADDITION TO THE SYSTEMIC DRUGS, THE JOINT MAYBE ASPIRATED ( WHEN ACCOMPANIED BY EXCESSIVE EFFUSION) AND STREPTOMYCIN AND ISONIAZID IN SOLUTION MAYBE INSTILLED INTRA-ARTICULARLY ONCE WEEKLY.

18. WITH THE QUIENSCENCE OF ACUTE LOCAL SIGNS, GENTLE ACTIVE AND ASSISTED KNEE BENDING EXERCISES SHOULD BE CARRIED OUT INTERMITTENTLY AFTER 12 WEEKS, MAYBE PERMITTED AMBULATION WITH SUITABLE ORTHOSIS / CRUTCHES. AFTER 6-12 MONTHS, IF SUITABLE RESPONSE PRESENT, CRUTCHES MAYBE DISCARDED AFTER 9-12 MONTHS, UNPROTECTED WT BEARING IS USUALLY PERMITTED.

19. OPERATIVE RX IN SYNOVIAL STAGE, IF DS IS NOT RESPONDING FAVORABLY, OR THE DIAGNOSIS IS UNCERTAIN EVEN AFTER SEMI-INVASIVE PROCEDURES, ARTHROTOMY AND SYNOVECTOMY SHOULD BE CARRIED OUT. IN ADDITION, REMOVAL OF LOOSE/RICE BODIES, DEBRIS, PANNUS, LOOSE ARTICULAR CARTILAGE, AND CAREFUL CURETTAGE OF OSSEOUS JUXTA-ARTICULAR FOCI SHOULD BE CARRIED OUT. POST OPERATIVELY, TRIPLE DRUG THERAPY, TRACTION, INTERMITTENT ACTIVE AND ASSISTED EXERCISES, SUITABLE BRACE AMBULATION SHOULD BE CONTINUED. IN ADULTS W ADVANCED ARTHRITIS OR INCASES WHICH RESULTED IN PAINFUL FIBROUS ANKYLOSIS DURING THE PROCESS OF HEALING, KNEE JT MAYBE BE TREATED BY ARTHODESIS. PROVIDES PAINLESS STABLE KNEE, PREVENTS RECRUDESCENCE CORRECTS DEFORMITY, AND PTS CAN DO LONG HOURS OF STANDING AND WALKING

20. IF THE DS HAS HEALED W A PAINLESS ROM(MIN - 20 DEGREE) IN AN UNACCEPTABLE POSITION, A SUPRACONDYLAR FEMORAL OSTEOTOMY MAYBE PERFORMED. FREQUENTLY RESULTS IN A MOBILE JT USEFUL FOR ANOTHER 10-15YRS.

21. SYNOVECTOMY The incisions Midline anterior or Medial/lateral parapatellar incision Some surgeons prefer two parapatellar incisions. Expose from the suprapatellar pouch proximally to the insertion of ligamentum patellae distally Skin, superficial fascia, deep fascia are cut Quadriceps expansion is cut about half to one cm away from the patella. By sharp dissection, a plane of cleavage is developed between the quadriceps expansion and suprapatellar synovial pouch. Excise the thickened synovial membrane starting from its proximal borders the suprapatellar pouch, articular margins of femoral and tibial condyles. Flex the knee joint to 90 degrees and inspect.Remove any loose bodies Remove as much as an unhealthy synovial membrane that can be removed from the cruciate ligaments and intercondylar fossa. Rotating tibia to either side may maximize the exposure of the membrane Above maneuver also helps inspection of menisci. Any obstructing intra-articular lesion or extra-articular adhesions should be cut’. When required, capsulectomy or capsulotomy is performed, to obtain the desired flexion on the operation table. The goal is to achieve a minimum of 90 degrees of flexion at the knee. The wound is closed over suction drainage

22. SYNOVECTOMY + DEBRIDEMENT IN CASES OF INFECTION, SUCH AS TUBERCULOSIS THE DISEASE MIGHT HAVE SPREAD BEYOND THE EXTENT OF THE SYNOVIAL MEMBRANE. IN SUCH CASES, DEBRIDEMENT OF THE JOINT IS ALSO UNDERTAKEN. THIS INVOLVES REMOVAL OF PANNUS, CURETTAGE OF DESTROYED BONE IF THE CAVITIES ARE LARGE, THESE MAY BE FILLED UP WITH CANCELLOUS BONE GRAFTS FROM THE NEARBY HEALTHY BONE. ALL THE DESTROYED TISSUE LIKE MENISCI, LOOSE AND DESTROYED ARTICULAR CARTILAGE, DESTROYED CAPSULE AND LIGAMENTS MAY BE CAREFULLY REMOVED.

23. POSTOPERATIVE CARE FOR SYNOVECTOMY KNEE THE LIMB IS KEPT ELEVATED ON A PILLOW WITH THE KNEE JOINT KEPT IN ABOUT 5 TO 10 DEGREES OF FLEXION WITH THE HELP OF A ROLLED TOWEL OR A SMALL PILLOW BEHIND THE KNEE. EXERCISES OF THE ANKLE AND STATIC QUADRICEPS EXERCISES ARE STARTED THE SAME DAY. KNEE BENDING EXERCISES ARE STARTED AFTER 24-48 HOURS AFTER REMOVAL OF SUCTION DRAIN. THE PATIENT MAY BE PUT ON CONTINUES PHYSIOTHERAPY. QUADRICEPS STRENGTHENING IS CONTINUED AND WEIGHT BEARING IS GRADUALLY ADDED.

24. ARTHRODESIS INDICATIONS: ADVANCED TUBERCULAR ARTHRITIS TUBERCULAR ARTHRITIS WITH TRIPLE DEFORMITY GROSS INSTABILITY PAINFUL ANKYLOSIS AFTER EARLIER OPERATIONS PTS WITH FAILURE OF PRIOR JOINT REPLACEMENT

25. CHARNLEY COMPRESSION CLAMP CHARNLEY RECOMMENDED COMPRESSION ARTHRODESIS IN TUBERCULOUS KNEE JT IN CHILDREN DEGREE OF COMPRESSION: 1 ROUND ,½ TO ⅓ OF THE ROUND 24HRLY FOR ABOUT 4-6 WKS, AFTERWARDS UPTO GROIN PLASTER CAST APPLIED EXCLUDING FOOD AND ANKLE. PLASTER TILL GROIN SHOULD BE USED IN BEST POSSIBLE FUNCTIONAL POSITION FOR 8-12 WEEKS. WT BEARING IN CAST COMMENCED 5-6WEEKS AFTER OPERATION WALKING PLASTER IS RETAINED FOR 3-6MONTHS

26. ARTHROPLASTY FOR TUBERCULOUS ARTHRITIS BESSER, WRAY, ROY (1987) PERFORMED ARTHROPLASTY INADVERTENTLY IN PREOPERATIVELY UNSUSPECTED CASES OF TB KNEE. IN GROSSLY DESTROYED PAINFUL KNEE, W OR W/O DEFORMITY, TRADITIONAL RX HAS BEEN ARTHRODESIS IN THE BEST FUNCTIONAL POSITION. HOWEVER, IMPOSES MULTIPLE RESTRICTIONS IN SITTING, PUBLIC TRANSPORT,MANY OTHER SOCIAL ACTIVITIES. ONCE THE KNEE ARTHROPLASTY IS INFECTED NO SATISFACTORY OUTCOME IS ACHIEVED BY RESECTION ARTHROPLASTY, ARTHRODESIS OR REVISION ARTHROPLASTY. MOST AUTHORS SUGGEST, THIS OPERATION ATLEAST 3-5 YEARS AFTER THE LAST EVIDENCE OF INFECTION.

27. STRING TEST: A NEW TOOL FOR TUBERCULOSIS DIAGNOSIS AND DRUG-RESISTANCE DETECTION IN CHILDREN

28. REFERENCES Imperiale BR, Nieves C, Mancino B, Sanjurjo M, Tártara S, Di Giulio ÁB, Palomino JC, Morcillo NS, Martin A. String test: A new tool for tuberculosis diagnosis and drug-resistance detection in children. Int J Mycobacteriol. 2018 Apr-Jun;7(2):162-166. doi: 10.4103/ijmy.ijmy_54_18. PMID: 29900894. Olivia J B, Demetri M E, James V B. Knee Arthrodesis: The Fate of the Contra Lateral Knee. Nov Tech Arthritis Bone Res. 2018; 3(1): 555604. DOI: 10.19080/NTAB.2018.03.555604 Tuberculosis of the Skeletal System - Dr. S.M. Tuli

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