Outline

1
Outline

• Epidemiology
• Presentation
• Investigations
• Optimal management

2
Tuberculosis notifications by site of disease
(pulmonary/non-pulmonary), England and Wales,
1982-2009
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TB - Epidemiology

• Rising prevalence nationally and locally
• Traditionally mostly pulmonary TB
• 60
• 40 extra-pulmonary TB
• Increasing proportion of EPTB (50)
• 10 of EPTB are joint TB

4
Joint TB - presentation

• Presentation is often insidious and atypical
• Can be sub-acute and therefore there can be a
  delay in diagnosis
• Painful joints may precede systemic symptoms by
  several weeks
• Sometimes is the tip of the iceberg of a
  multi-focal TB

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Joint TB - presentation

• Early
• Usually a single joint
• Painful
• No swelling or deformity
• Later joints may become warm and swollen
• Sometimes they have a fever
• Look for other symptoms eg cough

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Coventry TB rate by year 1999-2006
Courtesy Dr Gee
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Figure 4. Tuberculosis case reports and rates by
age group and place of birth, UK, 2008
8
Tuberculosis case reports and rates by place of
birth and ethnic group, UK, 2008
9
World health organisation
10
Three-year average tuberculosis case rates by
primary care organisation, UK, 2006-2008
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Joint TB -presentation

• Ask about previous TB/contact history
• But absence does not rule out TB or make it
  unlikely
• Ethnicity is important
• Think osteo-articular TB
• Have a high index of suspicion..
• In a young patient with a single chronic painful
  joint and from an area of high background
  incidence of TB

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TB

• Beware of the young patient (from an area of high
  incidence) with backache that doesnt go away
• Must also consider the diagnosis in pregnant
  ladies

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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

• Desai.J Bone Joint surg Br.1994
• 2. osteoarticular TB in a general hospital in
  the last decade.ruiz.clin microbiol infect.2003

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Joint TB - Management

• Standard quadruple therapy
• Rifampicin
• Isoniazid
• Pyrazinamide
• Ethambutol

short course chemotherapy for spinal
Tb.parthasarathy. journal of bone and joint
surgery.1999
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How long for?
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Joint TB - management

• Usually 6 months is standard
• No controlled trials for peripheral joint TB
• 6 months?
• 12 months?
• Do they require surgery?

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Joint TB - management

• 1A multicentre MRC study of spinal tuberculosis
  suggests good results can be achieved with 6-9
  months of treatment and this is currently the
  recommendation of The British Thoracic Society
  Guidelines/NICE

1.Fourteenth report of the Medical Research
Council Working Party on Tuberculosis of the
Spine. Int Orthop. 1999 23(2) 73-81
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Outcome at 5 years
Outcome Hong Kong Surgery6HRs No Hong Kong Surgery9HRs No Madras Surgery6HR No Madras 6HR No Madras 9HR No
Favourable 23 96 25 96 72 88 75 91 84 98
Unfavourable 1 4 1 4 10 9 7 8 2 2
Total 24 26 82 82 86
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Joint TB - management

• Even quite extensive joint disease with severe
  radiographic changes can resolve with medical
  treatment alone

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Joint TB - management

• However, if treatment is delayed, there can be
  considerable loss of function and a requirement
  for extensive surgical intervention.

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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

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Supplementary slides
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Short course chemotherapy

• MRC working party on TB of spine
• 3 countries Hong Kong, India and Korea
• 3 randomised trials
• 5 year assessment

International Orthopaedics 1999 23 73-81
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Short course chemotherapy

• Comparison of .
• Hong Kong radical resection 6HRS
• Ambulant therapy 6HR (medical)
• Ambulant therapy 9HR (medical)

International Orthopaedics 1999 23 73-81
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Short course chemotherapy

• Outcomes
• Unfavourable outcome
• Favourable outcome
• (full functional activity, radiologically
  quiescent, no myelopathy with functional
  impairment, modification of therapy)

International Orthopaedics 1999 23 73-81
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Therapy

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

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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

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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