Osteoarticular TB  Management: INICET Orthopedics 

What is Osteoarticular TB?

Osteoarticular is also known as skeletal tuberculosis. In general, Skeletal T.B. is highly incident in young adults. It is uncommon in old age. Human-type Tubercle bacilli is the main causative agent in India. Bovine type which spreads through raw milk is less common in India.Common mode of spread is Hematogenous (like pyogenic osteomyelitis). 99% of skeletal T.B. patients will have pulmonary T.B. and later invade bone through hematogenous route.

How to treat Osteoarticular TB

1st line therapy (HRZES)

Isoniazid (INH) (H)

• Bacteriostatic
• Dose: 5 mg/kg/day
• It inhibits cell wall synthesis.
• Idiosyncratic complications: Hepatotoxicity and Peripheral neuropathy

Rifampicin ( R)

• Bactericidal
• Dose: 10 mg/kg/day
• Complications: Hepatitis
• Red color urine (not a medical concern)

Pyrazinamide (Z)

• Bactericidal
• Dose: 25 mg/kg/day
• Complications: GI upset

Ethambutol (E)

• Bacteriostatic
• Dose,15 mg/kg/day
• Complications: Subacute myelo-optic neuropathy (SMON)

Streptomycin (S)

• Bactericidal
• 15 mg/kg/day
• Complications: Ototoxicity, Nephrotoxicity, Neuromuscular blockade

2nd line therapy

Thioacetazone

• Bacteriostatic
• 2.5 mg/kg/day

Para amino salicylic acid (PAS)

• Bacteriostatic
• 10 gm/day

Ethionamide

• Bacteriostatic
• 15 mg/kg/day

Cycloserine

• Bacteriostatic
• 1 gm/day
• Complication: Psychosis

Indications for surgery

Patients having a neurological deficit

• No recovery even after 3-4 weeks of ATT
• Worsening of paraplegia
• Spastic paraplegia with severe and uncontrollable spasms of the legs

Patients with no neurological deficit

• Extensive paravertebral abscess and not responding to ATT.
• Mechanical instability
• Ex: When bilateral facet joints are affected

Surgeries in practice

• Costo-transversectomy
• Anterolateral decompression: Hongkong procedure, Antero Compression, and spinal fusion
• Posterolateral or Transpedicular approach
• This is predominantly used.

Babulkar and Pandey Clinico-Radiological Classification

Stage I- Stage of Synovitis

• Irritable hip
• Increased FABER (mnemonic) of the hip joint
  • Flexion
  • Abduction
  • External rotation
• Apparent lengthening due to FABER
• Terminal movements will be restricted by 25%

Stage II- Stage of Early Arthritis

• Articular cartilage damage
• Increased FADIR of the hip joint
  • Flexion
  • Adduction
  • Internal rotation
• Apparent limb shortening due to FADIR.
• Gluteal, Quadriceps muscle wasting
• All ranges of movements (ROM) are restricted by 50%
• X-ray shows osteopenia and narrowing of joint space

Stage III- Stage of Late Arthritis

• Significant articular surface destruction
• Marked FADIR
• True limb shortening
• Gross restriction of movements usually more than 50%
• X-ray shows marked subchondral destruction

Stage IV- Stage of Pathological Dislocation

• Gross destruction of the femoral head or pathological dislocation of the superior acetabular margin
• Wandering or Travelling Acetabulum- Upward displacement of the head of the femur and may be out of the ilium.
• Marked shortening.
• Gross restriction in all range of movements
• Protrusio Acetabuli- Medial protrusion of the head of the femur through destroyed acetabulum.

Treatment

Stage of Synovitis

• Rest and mobilization exercises
• Traction
• ATT

Stage of Arthritis

• Non-weight-bearing ROM exercises.
• ATT
• If unresponsive, then
  • Synovectomy (Removal of synovium).
  • Joint debridement

Stage of pathological Dislocation

• Girdle stone's Excision Arthroplasty
• Total hip replacement

Important points to remember 

• Night cries (Acute pain during the night times) are characteristic of Skeletal T.B.
  • Night cries are also seen in Osteoid osteoma.
  • This is because during nighttime skeletal muscles relax and synovium (rich in nerve innervations) stretches causing pain.
• For Skeletal TB, the WHO recommends.
  • Category 1 treatment, 2 months of HRZE followed by 4 months of HR (Cat-1)
• Hematogenous spread is either arterial or venous spread:
  • The arterial arcade of subchondral regions facilitates infection spread to the para-discal region.
  • Batson's paravertebral venous plexus is a valveless plexus that spreads infection to the central vertebral body.
• Primary deformities: Loss of normal cervical and lumbar lordosis (due to paraspinal muscle spasm)
• Secondary deformity could be GIBBUS.
  • Upon palpation of the spine bony protrusion can be seen
  • Due to damage to the vertebral body, crowding of more than one spine processes occurs leading to protrusion- GIBBUS.
  • GIBBUS is seen predominantly in the thoracic spine.
• Spinal nerve root compression due to Pott's paraplegia
• Professor SM Tuli and TK Shanno Sundharam: Extensive work in TB

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