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Tuberculosis Tuberculosis Of Bone And Of Bone And
JointJoint
Tuberculosis Tuberculosis Of Bone And Of Bone And
JointJoint presenter
Dr. Sanjeev Kumar Singh
M.S Ortho (PGT)
KMCH, Katihar
presenter
Dr. Sanjeev Kumar Singh
M.S Ortho (PGT)
KMCH, Katihar
HistoryHistoryHistoryHistory
Hippocrates (460-360 BC) – relation between
pulmonary disease & spinal deformity
Percival Pott (1779) described Spinal TB
Lennac (1781-1826) described tubercle
Tubercle bacillus discovered in 1882
Described in Rigveda & Athurveda
Charak Samhita, Shushruta - Yakshma
Hippocrates (460-360 BC) – relation between
pulmonary disease & spinal deformity
Percival Pott (1779) described Spinal TB
Lennac (1781-1826) described tubercle
Tubercle bacillus discovered in 1882
Described in Rigveda & Athurveda
Charak Samhita, Shushruta - Yakshma
Epidemiology & PrevalenceEpidemiology & PrevalenceEpidemiology & PrevalenceEpidemiology & Prevalence
World - 30 million
WHO data- 3 million mortality / yr
India- 1/5th of total TB population
2-3% - skeletal involvement
World - 30 million
WHO data- 3 million mortality / yr
India- 1/5th of total TB population
2-3% - skeletal involvement
General ideasGeneral ideasGeneral ideasGeneral ideas
Tuberculosis is a chronic infectious disease
caused by the tubercle bacilli. Insidious in onset.
TB of bone and joint is merely local
manifestation of a general disease.
Most TB lesion of bone and joint appear at least
2to3 years of the onset of the primary lesion,
Commonest age - first three decades ,can occur at
any age . Equally both the sexes.
Tuberculosis is a chronic infectious disease
caused by the tubercle bacilli. Insidious in onset.
TB of bone and joint is merely local
manifestation of a general disease.
Most TB lesion of bone and joint appear at least
2to3 years of the onset of the primary lesion,
Commonest age - first three decades ,can occur at
any age . Equally both the sexes.
Predisposing factorsPredisposing factorsPredisposing factorsPredisposing factors
Malnutrition
Poor sanitation
Overcrowding
Immunodeficiency
imunosupressive
drug
Malnutrition
Poor sanitation
Overcrowding
Immunodeficiency
imunosupressive
drug
Diabetes
Alcohol abuse
Old age
Drug abuse
trauma
Diabetes
Alcohol abuse
Old age
Drug abuse
trauma
Pathogenic organism Pathogenic organism tubercle bacillustubercle bacillus
Pathogenic organism Pathogenic organism tubercle bacillustubercle bacillus
tubercle bacillus may be either
the human type or bovine type
human type----involves lung,
transmission airborne by droplet
bovine type----involve the
intestine or alimentary tract ,non-
pasteurized/unboiled milk;
tubercle bacillus may be either
the human type or bovine type
human type----involves lung,
transmission airborne by droplet
bovine type----involve the
intestine or alimentary tract ,non-
pasteurized/unboiled milk;
PredilectionPredilectionPredilectionPredilection
Spine : thoracic , thoraco-lumbar, lumbar,
cervical, cervico-dorsal and
L/S
Hip
Knee
Ankle
Elbow
Hand
Shoulder
Spine : thoracic , thoraco-lumbar, lumbar,
cervical, cervico-dorsal and
L/S
Hip
Knee
Ankle
Elbow
Hand
Shoulder
LocationLocationLocationLocation
Bone: growing age - metaphysis
adults - end of bone
Joint: Synovial membrane
Spine: Paradiscal
Anterior
Central
Appendeges(posterior)
Bone: growing age - metaphysis
adults - end of bone
Joint: Synovial membrane
Spine: Paradiscal
Anterior
Central
Appendeges(posterior)
PathogenesisPathogenesis PathogenesisPathogenesis
spread mainly haematogenous
most common route to the vertebral body is through
Batson's venous plexus
Osteoarteoarticular lesion occcurs 2-3yrs after primary
focus
spread mainly haematogenous
most common route to the vertebral body is through
Batson's venous plexus
Osteoarteoarticular lesion occcurs 2-3yrs after primary
focus
PathologyPathologyPathologyPathologySynovium – swollen & congested,
synovial effusion
Inflammation – epitheloid cells, langhans
giant cells, tubercle (soft/hard), caseation
Pannus, Rice bodie, Kissing Lesion
Cold abcess, TB Sequestra
Intervertebral disc and cartilage not
involved
Synovium – swollen & congested,
synovial effusion
Inflammation – epitheloid cells, langhans
giant cells, tubercle (soft/hard), caseation
Pannus, Rice bodie, Kissing Lesion
Cold abcess, TB Sequestra
Intervertebral disc and cartilage not
involved
Disease typeDisease typeDisease typeDisease type
Pathological:
- Caseous Exudative type (severe)
- Granular type
Pathological:
- Caseous Exudative type (severe)
- Granular type
Clssification of articular T.BClssification of articular T.BClssification of articular T.BClssification of articular T.B
Clinical featuresClinical featuresClinical featuresClinical features
Age- 1rst three decade
Insidious onset
Monoarticular / monosseous
Constitutional sign and symptom
(wt. loss, lassitude, low grade pyrexia,
anorexia, night sweat, tachycardia,
tachypnoea, anemia)
Age- 1rst three decade
Insidious onset
Monoarticular / monosseous
Constitutional sign and symptom
(wt. loss, lassitude, low grade pyrexia,
anorexia, night sweat, tachycardia,
tachypnoea, anemia)
Local symptoms and signsLocal symptoms and signsLocal symptoms and signsLocal symptoms and signs
Monoarticular or mono-osseous involvement
Limp, joint movement restricted
Stiffness
Early stage: limitation of motion;
Late stage: fibrous ankylosis
Deformity: bone destruction, gibbus result
from the lesion of thoracolumbar spine,
Monoarticular or mono-osseous involvement
Limp, joint movement restricted
Stiffness
Early stage: limitation of motion;
Late stage: fibrous ankylosis
Deformity: bone destruction, gibbus result
from the lesion of thoracolumbar spine,
Local symptoms and signsLocal symptoms and signsLocal symptoms and signsLocal symptoms and signs Muscle atrophy
Muscle spasm
Night cry
Doughy swelling
Fluctuated swelling-cold abscess formed
Sinus or fistula
Muscle atrophy
Muscle spasm
Night cry
Doughy swelling
Fluctuated swelling-cold abscess formed
Sinus or fistula
investigationinvestigationinvestigationinvestigation
CBC
ESR
CXR
X-Ray of joint / bone
Tuberculin test
Biopsy
Smear and culture
CBC
ESR
CXR
X-Ray of joint / bone
Tuberculin test
Biopsy
Smear and culture
Guinea pig inoculation
PCR
ELISA
Isotopes scintigraphy
CT scan
MRI
Guinea pig inoculation
PCR
ELISA
Isotopes scintigraphy
CT scan
MRI
X-RAYX-RAYX-RAYX-RAY
XRAY HIP XRAY HIP XRAY HIP XRAY HIP
Treatment:Treatment: general caregeneral careTreatment:Treatment: general caregeneral care
Nutritional support
Fresh air, warm dry climate ,sanatorium life, hygienic and nursing care.
T/t of concomittant disz
Immunomodulation drugs
Nutritional support
Fresh air, warm dry climate ,sanatorium life, hygienic and nursing care.
T/t of concomittant disz
Immunomodulation drugs
local treatmentlocal treatmentlocal treatmentlocal treatment
Immobilization
Traction
Active gaurded intermittent mobilization of joint
Ambulation
Immobilization
Traction
Active gaurded intermittent mobilization of joint
Ambulation
ATTATTATTATT
1st line drugs:
- Isoniazid (INH)
- Rifampicin (R)
- Pyrizinamide (Z)
- Ethambutol (E)
- Streptomycin (S)
1st line drugs:
- Isoniazid (INH)
- Rifampicin (R)
- Pyrizinamide (Z)
- Ethambutol (E)
- Streptomycin (S)
ATT…ATT…ATT…ATT…2nd line drugs:
- Thiacetazone
(TZN)
- PAS
- Amikacin
- Kanamycin
- Capreomycin
- Ethionamide
- Cyclocerine
2nd line drugs:
- Thiacetazone
(TZN)
- PAS
- Amikacin
- Kanamycin
- Capreomycin
- Ethionamide
- Cyclocerine
Newer drugs:
- Ciprofloxacin
- Ofloxacin
- Clarithromycin
- Azithromycin
- Rifabutin
Immunomodulators:
- Levamisole
Newer drugs:
- Ciprofloxacin
- Ofloxacin
- Clarithromycin
- Azithromycin
- Rifabutin
Immunomodulators:
- Levamisole
Middle Path RegimeMiddle Path RegimeMiddle Path RegimeMiddle Path RegimeIntensive phase (5-6 mth):INH+R+Ofloxacin
Continuation phase (7-8 mth) :
INH+Z (3-4 mth), then INH+R (4-5 mth)
Prophylactic phase(4-5 mth):
INH+E (4-5 mth) This regime is for OPD patients
For Indoor pts, any of above drugs is replaced by
Streptomycin except INH
Intensive phase (5-6 mth):INH+R+Ofloxacin
Continuation phase (7-8 mth) :
INH+Z (3-4 mth), then INH+R (4-5 mth)
Prophylactic phase(4-5 mth):
INH+E (4-5 mth) This regime is for OPD patients
For Indoor pts, any of above drugs is replaced by
Streptomycin except INH
DOTsDOTsDOTsDOTsIt is strategy to ensure cure by providing the most effective
medicine and confirming that it is taken.
Two Phase t/t:
1. Intensive phase (2-3 mth)
2. Continuation phase (5-6 mth)
Category-1
IP -- 2(HRZE)3
CP -- 4(HR)3
It is strategy to ensure cure by providing the most effective
medicine and confirming that it is taken.
Two Phase t/t:
1. Intensive phase (2-3 mth)
2. Continuation phase (5-6 mth)
Category-1
IP -- 2(HRZE)3
CP -- 4(HR)3
DOTs……DOTs……DOTs……DOTs……
Category-2
IP -- 2(HRZES)3 + 1(HRZE)3
CP – 5(HRE)3
Category-3
IP – 2(HRZ)3
CP – 4(HR)3
Category-2
IP -- 2(HRZES)3 + 1(HRZE)3
CP – 5(HRE)3
Category-3
IP – 2(HRZ)3
CP – 4(HR)3
Surgical Treatment….Surgical Treatment….Surgical Treatment….Surgical Treatment…. Miliary disseminations of the disease has been
reported when surgery was carried out without adequate chemotherapy coverage.
Before operation, at least general supportive nutrition and anti-microbial agents were performed for 2-4 weeks, and satisfied following index:
ESR: show the normal
General condition improved-good appetite, body weight grow etc.
Miliary disseminations of the disease has been reported when surgery was carried out without adequate chemotherapy coverage.
Before operation, at least general supportive nutrition and anti-microbial agents were performed for 2-4 weeks, and satisfied following index:
ESR: show the normal
General condition improved-good appetite, body weight grow etc.
Indications of OperationIndications of OperationIndications of OperationIndications of Operationlarge sequestrum
big abscess which can not be absorped
sinus
when TB osteitis or synovitis is uncontrolled and
has a progress to true arthritis
spinal TB with paraplagia
early TB arthritis(1/3 destruction of joint surface)
large sequestrum
big abscess which can not be absorped
sinus
when TB osteitis or synovitis is uncontrolled and
has a progress to true arthritis
spinal TB with paraplagia
early TB arthritis(1/3 destruction of joint surface)
ContraindicationsContraindicationsContraindicationsContraindications
General condition is not good and low resistance condition, such as too young or old
The patient with other vital visceral diseases can not bear the operation
Another foci of active TB is present
Tubercle bacilli are resistant.
General condition is not good and low resistance condition, such as too young or old
The patient with other vital visceral diseases can not bear the operation
Another foci of active TB is present
Tubercle bacilli are resistant.
Surgical TreatmentSurgical TreatmentSurgical TreatmentSurgical Treatment
When abscess formation threatens the
integrity of neighboring structure,
Removal of the infected foci is indicated,
including curettage, debridement,
synovectomy, arthrodesis, Osteotomy.
When abscess formation threatens the
integrity of neighboring structure,
Removal of the infected foci is indicated,
including curettage, debridement,
synovectomy, arthrodesis, Osteotomy.
Thankyou;;Thankyou;;Thankyou;;Thankyou;;