ORATION

Ind. J. Tub., 1993, 40,109

TUBERCULOSIS OF BONES & JOINTS*

B. Sankaran1

I am grateful to the Tuberculosis Association of India and Lupin Laboratories for giving me an opportunity to give this oration. I would like to dedicate this oration to persons in the field of orthopaedic surgery who were responsible for the modern concepts of treatment of tuberculosis of bones & joints and to my teachers and colleagues in the profession : Prof. Russel Hibbs & Prof. Alan de Forest Smith of New York Orthopaedic Hospital; Prof. John Charnley of Manchester; Prof. Girdlestone of Oxford & Mr. J.C. Wilkinson of Wrightington (U.K.); Prof. Hodgson & Prof. Stock of Hongkong; My teacher and mentor. Prof. M.G. Kini of Madras and my senior colleague, Prof. P.K. Duraiswami. This oration would have been impossible without the support of Prof. S.M. Tuli's classic Tuberculosis of Bones & Joints. To him I owe a deep debt of gratitude.
History The tubercle bacillus has co-existed with Homo sapiens since time immemorial. The Rig Veda, Atharva Veda (3000 - 1800 BC) and Samhita of Charaka & Sushruta (1000 & 600 BC) recognized the disease as Yakshma in humans, which by its symptoms and signs could only be tuberculosis of the lungs.1 Tuberculous lesions have been found in Egyptian mummies and the Greco Roman civilisation recognised phthisis or consumption as a problemof the lungs.

lion globally and approximately 30% or 10 million cases exist in India,21-3% of the 10 million have involvement of bones & joints. The predisposing factors are malnutrition of the protein calorie type, environmental conditions and living standards such as poor sanitation, over crowded housing and slum dwelling. Trauma as a causative factor is debatable, but cases following trauma have been reported.3 Repeated pregnancies and lactation in women is also a factor. A diabetic status is an important pre-disposing factor. Acquired immuno deficiency syndrome has certainly led to a resurgence of tuberculosis. Osteo-articular disease is always secondary to a primary lesion in the lung. Lymph node involvement (mediastinal, mesenteric or cervical) and visceral lesions, like renal and hepatic tuberculosis, could also be concomitant forms, particularly in diabetics.
Bacteriology

Prevalence

The prevalence of the disease is around 30 mil*

Tubercle bacilli are mainly of two types : human & bovine. According to Western reports, bovine tubercle bacilli are responsible for 80% of osteo-articular lesions below the age of 10 years. The human bacillus is responsible for almost all the cases of osteo-articular tuberculosis in India. Bacteriological confirmation by identification of the bacillus in cold abscess aspirate or biopsy taken from the site of the lesion (bone soft or granulation tissue) or culture of bacilli on Lowenstein Jensen medium would be necessary in certain cases. This may not, however, be positive in all the cases 4'5. In the Indian scenario, various studies have shown varying rates of confirmation : 40-80% by Dahl,6 60.5% by Tuli7 and 87% by Lakhanpal* after culture and guinea pig

TAI-Lupin Oration, 1992 prepared in collaboration with Dr S.M. Tuli and delivered at the 47th National Conference on Tuberculosis & Chest Diseases, Bombay, 26th to 28th November, 1992. 1. Director General of Health Services, Government of India (Retired) and Director, WHO Headquarters Office, Geneva (Retd.). Correspondece: Dr. B. Sankaran, Sitaram Bhartia Institute of Science and Research Centre, B-16, Mehrauli Institutional Area, New Delhi-110 016

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inoculation. Dobson et al9 have confirmed Dahl's findings of 19516 and 1973. Atypical myco-bacteria, other than M. tuberculosis fiumanis or bovis have been reported in lesions of the synovial sheath. The transmission of atypical mycobacteria cannot be by contact. The following factors would have to be considered in this regard : (1) trauma, (2) local steroidal injection, (3) surgical trauma, (4) diabetic status, (5) use of chemical immunosuppressive drugs like cyclosporin in organ transplantation and (6) acquired immuno-deficiency syndrome.
Aetio-pathogenesis

Osteo-articular tuberculosis can occur in the spine, hip, knee, foot, elbow, wrist, hand, shoulder and as diaphysial foci. Mandible and temporomandibular joint lesions have not been reported. The major method of spread is haematogenous through arteries, and veins as a result of back flow. The most common method of spread to the vertebral body is through Batson's prevertebral venous plexus.
Clinical Aspects

I shall now discuss the various clinical aspects according to the site of the lesion.
(A) Tuberculosis of Spine

planes. A deformity, in the spine can be present as kyphosis along with local tenderness and proximal lymphadenopathy. Tuberculosis of the spine has the following distribution : thoracic - 42%, thoraco-lumbar - 12%, lumbar - 26%, cervical -12%, cervico-dorsal - 5% and lumbo-sacral - 3%. The lesion in the spine is, most often, para discal in location with destruction of the disc, reduction of the disc space and concomitant destruction of the vertebral bodies, on either side of the disc. The destruction could also be on the anterior aspects of the vertebral body extending behind the anterior longitudinal ligament to the sequential vertebrae. It can also be limited to the centrum of the vertebrae resulting in concentric collapse and should be differentiated from compression of the vertebrae secondary to primary or metastatic malignant disease of the vertebal body. Lastly, posterior element disease can occur behind the anatomical neuro-central-synchondrosis in 6% of cases.18 The disease can involve vertebral bodies at two or three different sites and these are referred to as skipped lesions. The lesion in the spine is almost always secondary to a demonstrable primary focus elsewhere15,19,20 in the body. The average number of vertebrae that are seen to be destroyed radiologically has been shown to be about 3.0 in children and 2.5 to 3.8 in adults.21,22,23,24

The commonest skeletal lesion is the vertebral lesion which is responsible for 50% of all bone & joint tuberculosis. The estimated number of spinal tuberculosis cases in India is between 30,000 and 90,000 cases. A number of authors have confirmed the high occurrence.10'17 The commonest age of occurrence is the first three decades of life but it can occur at any age and has been reported from the first year of life to among those 80 years old. The disease occurs with equal frequency in both the sexes. In most cases, the lesion is insidious in onset and only rarely is there an acute manifestation. The most common general symptoms are weight loss, lassitude and evening rise of temperature. Locally, there is stiffness, painful restricted joint movements in all die planes and severe spasm of the surrounding muscles. If the lesion has been present for a sufficiently long time, a cold abscess occurs in the soft tissues, tracing its way through the inter muscular

Abscess Pathways
Since the cold abscess is the most common and important criterion for establishing the diagnosis of tuberculosis of the spine, the anatomical path of the cold abscess is of great importance. In any region, prevertebral accumulation of pus is a very noticeable feature. In the cervical spine, it presents as a retropharyngeal or prevertebral shadow, but could also be anatomically located in the following sites : (1) behind the prevertebral fascia, (2) along the posterior border of sternomastoid muscle, (3) in the supraclavicular area and, rarely, (4) down the mediastinum to become an upper mediastinal mass visible on X-ray, (5) in the back of the neck, lateral to the posterior spinal muscles and (6) tracking down the brachial plexus to present in the axilla or even at the elbow joint, along one of the main nerves of the upper extremity. A thoracic cold abscess is quite frequently

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prevertebral or posterior mediastinal in location. It could, however, track along the intercostal nerves to present at the following sites : (a) anterior end of intercostal space, (b) abdominal wall behind the rectus sheath (c) midaxillary line and (d) along the posterior division of the intercostal nerve, lateral to the sacro-spinalis muscle mass. In lower thoracic lesions, below D10, the cold abscess might take various routes. The abscess can track along (a) behind the lateral lumbo-costal arch of the origin of the diaphragm and present in the retronephritic space or in the layers of the anterior abdominal wall, (b) behind the medial lumbo-costal arch of the origin of the diaphragm and enter the psoas sheath and present as a psoas cold abscess, palpable above the inguinal ligament or on the medial aspect of the thigh, if it traverses below the inguinal ligament, (c) it can go behind the median arcuate ligament of the origin of the diaphragm along the aorta and its branches and can, thus, have wider sites of presentation, as the lumbar cold abscess does. A lumbar cold abscess can spread along the aorta and its branches to present at the (1) ischiorectal fossa, (2) in the buttock, under the gluteus maximus, (c) along the psoas sheath or (d) in the lumbo-dorsal (Petit's) triangle. It can also track down along the femoral or abturator artery and present on the medial side of the thigh, femoral triangle, popliteal fossa or on the medial side of the tendo-achilles. Thus, the anatomical presentations of a cold abscess can be far away from the site of the lesion. Fortunately, such far away presentations are becoming rarer because of early diagnosis and early clinical suspicion of the disease. The spread of cold abscess has been extensively discussed by Lee Macgregor in his book 'Synopsis of Surgical Anatomy'. Diagnosis The investigations to establish the diagnosis are primarily X-ray examination and imaging techniques such as computerized axial tomography (CAT) and magnetic resonance imaging (MRI). In cases with paraplegia but without radiological evidence of skeletal lesion, or where there is post element disease, and in a situation where CAT and MRJ are not available, a contrast medium study is indicated. Other investigations including a blood

profile with erythrocyte sedimentation rate, diabetes status and X-ray or CAT controlled needle aspiration biopsy. Radiological Appearances The para discal lesion shows a reduction in disc space before osseous destruction occurs, but focal osteoporosis is seen even earlier than disc space reduction. One of the most important diagnostic radiological criteria is the delineation and study of para vertebral shadows. In the cervical region, the normal retropharyngeal space is 1.5 cms below the cricoid cartilage. Any increase beyond this should make one suspect the possibility of an increase in the retropharyngeal shadow. In respect of the lower cervical 6th and 7th vertebrae and lst-4th dorsal vertebrae, excellent quality X-rays are vital otherwise lesions in this area are frequently missed. In the dorsal region, below the 4th dorsal vertebra, typical fusiform Bird Nest abscess is commonly seen. A very large abscess on both the sides of the aorta, with broadening of die mediastinum, and the lower margin extending to the level of the medial arcuate ligaments is a common finding. Abscess can sometimes be globular in shape which indicates accumulation of pus under tension. Intra spinal spread of abscess into extra dural space cannot normally be detected on routine radiograms. In the lumbar region, a psoas abscess can be picked up on antero-posterior X-ray by enlargement seen in the psoas shadow. Retro-peritoneal accumulation of pus may extend downwards to the presacral region and is seen behind the rectum. Specific radiological appearances in the spine may include, besides the types described above, an aneurysmal type scalloping (concave erosion) along die anterior margin of the vertebral body, mostly as a result of cold abscess present under the anterior longitudinal ligament. This anterior type of lesion is more common in children. Rarely, lateral curvature in the spine (scoliosis) may be seen but the most common is the kyphotic deformity, i.e. increase in the antero-posterior curvature. Spectacular advances in modern imaging technology, like computerized axial tomography and magnetic resonance imaging have made diagnosis of tuberculosis of the spine much easier. Lesions can now be picked up much earlier, such as single

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localized centrum lesion, facetal joint lesion and post element disease. In a patient with paraplegia, the value of CAT scan and MRI is that it shows the extent of extra dural pressure on the spinal cord, the nature of the pressure and the possible functional restoration of the cord after decompression of the abscess. The exact rib that has to be excised and the extent of calcification of the abscess or granulation tissue can also be demonstrated. The diagnosis and specific method of management, therefore, become more scientific. Differential Diagnosis Following conditions have to be considered for differential diagnosis: 1. Traumatic compression fracture : Normally, the anterior wedging of vertebra and no involvement of the disc space help. These fractures can be of multiple vertebrae and no abscess shadow or para-vertebral mass is visualized on X-ray examination. 2. Pyogenic osteomyelitis : The clinical presentation is acute with high rise of temperature. The ESR is well above 100 mm/hr. There is a possibility of septicemia. Radio1 logical destruction is limited to one or two vertebrae and the abscess is limited to just one area. 3. Salmonella osteomyelitis : This can be easily missed. Sickle cell disease individuals are more prone to get it. Drainage of abscess and culture of organism helps to establish a diagnosis. 4. Myotoma actinomycosis : It is a rare condition and difficult to differentiate. The diagnosis needs a radial laminectomy and biopsy examination. 5. Brucellosis : Drainage and culture of bacilli are needed. 6. Luetic : A rare condition confirmed by blood examination for syphilis. 7. Echinococcus : The type of destruction in vertebral body is as if punched out with concomitant destruction of the disc space; soft tissue extension and hepatic involvement are present. 8. Chronic infection : Rheumatoid (Seronegative) involvement and ankylosing spondylitis can be differentiated with haematological investigations; no abscess shadow is seen radiologically.

9. Metabolic skeletal osteoporosis : Senile, post menopausal; the density of bones is decreased, loss of osseous trabecule is noted. Multiple compression fractures of vertebral bodies can be noticed. No paravertebral mass or abscess shadow is noted. It is important to exclude hyperthyroidism and hyperparathyroidism (primary or secondary) as cause of compression fractures of vertebrae. In all these problems, the inter-vertebral disc space is well preserved. The same is true of cortisone induced osteoporosis. 10. Tumour of the vertebral column : Either benign or malignant may have to be differentiated from skeletal tuberculosis. Malignant lesions may either be primary or secondary. Benign lesion such as haemangioma, osteoblastoma and osteoid osteoma should be thought of when the lesion is restricted to a single vertebra. Histocytosis like eosinophilic granuloma in children might need a fine needle aspiration biopsy under computerized axial tomography scan control. Giant cell tumour and aneurysmal bone cyst show multiple vertebral destruction with total destruction of the entire body including posterior elements. Primary malignant bone lesion could be a chondro-sarcoma of the vertebral body, multiple myeloma or solitary plasmo-cytoma and lymphoma of bone. Ewing's sarcoma of the spine is rare but must be thought of. Secondary metastatic deposits can occur in adrenal medulloblastoma in children. Other tumours that can metastasize in bones are renal, lung, thyroid, breast, prostate and G.I. tract tumours. All malignant tumours have a characteristic bone destruction pattern but the intervertebral disc space is well preserved. Most present as paraplegia or quadriplegia depending on the site of the lesion. Clinical presentation is with weight loss, severe anaemia, and very high ESR. Fine needle aspiration biopsy under X-ray control is necessary to establish a diagnosis. The other possible pathological lesions that might simulate tuberculosis of the spine are osteochondritis of the Scheurmann type and hemivertebrae. These are rare lesions and have specific radiological appearances that help diagnosis. Complications The most single important complication is paraplegia or quadriplegia. Occurrence of paraple-

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gia is 10-30%. One half of all reported paraplegias are due to tuberculosis of thoracic and thoracolumbar regions. If there are 30,000 to 90,000 cases of tuberculosis of the spine, patients with paraplegia would be between 7,500 and 22,500, out of a total of 15,000 to 45,000 paraplegics in the country. Nobody has studied this aspect in our country till today and the numbers given are pure guesstimates. It is important, therefore, that some body should take up the study of this important problem since the entire sequence of disease leading to complication is preventable. The vertebral regions commonly involved in paraplegia of tuberculosis origin are thoracic, thoraco-lumbar, cervical, lumbar and cauda equina, in that order. Griffiths, Seddon & Roaf25 classified tuberculous paraplegia in two grades, Grade A and Grade B : Grade A with early onset, within 2 years after onset of symptoms of tuberculosis, and grade B with late onset, i.e. after more than 2 years. Grade B paraplegia might be due to recrudescence of disease, mechanical pressure as a result of severe kyphosis, inadequate blood supply to the spinal cord as a result of slow exsanguination resulting in a fibrous cord, and patchy meningitis. Grade B, in general, has a poor prognosis which must be explained to the patient. Grade A paraplegias (Pott's paraplegia) have also been described26-27 as: Grade I : The patient is not aware of the problem. On clinical examination, there are signs of compression, usually exhibited by long tract involvement signs or segmental paresis. The patient is able to walk. Grade II: There is evident spasticity but the patient is able to walk, often with jumpiness in the gait. Long tract involvement signs are significantly present. Grade III : The patient is bed-ridden and has spastic paraplegia in extension with demonstrable neurological deficits, both sensory and motor. Grade IV : Paraplegia occurs with flexor spasm. There is bladder and bowel involvement and total sensory and motor loss. The prognosis is poor. Treatment Antituberculosis drug regimens : The Medical Research Council of the United Kingdom carried

out a series of trials in the late 60's and early 70's to establish the antituberculosis regimens necessary for treatment of tuberculous lesions of bones and joints. Though the emphasis in the trials was primarily on tuberculous spine, the recommendations are for all types of musculo-skeletal lesions. Briefly, there is a four drug regimen for the first three months with dosages of the drugs based on age and body weight of the patient. The drugs of choice are Rifampicin, Isoniazid, Ethambutol and Pyrazinamide, followed by three drugs, i.e. Rifampicin, Isoniazid and Ethambutol for 16 to 24 months. If toxicity develops, the offending drug is changed. Allergic reaction can occur to any drug; careful attention must be paid to toxicity. Thus, Streptomycin can effect the VIII nerve resulting in deafness or vestibular functional derangement. Rifampicin can produce hepatotoxicity and hence SCOT & SGPT levels must be monitored. Ethambutol can produce depressed thyroid function. The major aim of treatment is to prevent paraplegia. Most authors have adopted the use of 4 anti-tuberculosis drugs for a period of three months initially followed by three drugs for 18 to 24 months. The drugs used are Streptomycin, Rifampicin, Isoniazid, Ethambutol and Pyrazinamide. In children below the age of 12 years, both Streptomycin and Rifampicin are advocated by paediatricians. The commonly followed treatment modality is the middle path, i.e. bed rest, drugs, periodic review of progress by X-ray and ESR done every 4 weeks. A careful detailed neurological examination every 3 or 4 days is mandatory. If there is an increase in neurological deficit, surgical intervention becomes desirable. I personally advise surgery in all cases of tuberculous quadriplegia, paraplegia due to upper dorsal tuberculous lesion, when there is grade IV type paralysis, and where investigations have indicated extradural spread of the cold abscess or granulation tissue. However, if there is improvement, on conservative treatment, it is continued for a minimum of 18 months. Auxiliary Treatment : Steroids are not recommended to be given routinely. Short term steroid therapy can be given in patients who are in a moribund state, till anti-tuberculosis treatment starts acting or when patchy meningitis is present. The addition of steroid might prove crucial. Short term therapy with anabolic steroids in debilitated malnourished patients enhances the protein intake but

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it should be avoided in women and children. I have always practised the following, as indications for surgery, besides the above given criteria: (1) Neurological complications which fail to respond to conservative care. (2) Paraplegia of the flexor spasm type, with bladder and bowel involvement and sensory deficit. (3) Neurological status remaining static, or (4) Where the diagnosis remains doubtful. (5) Mechanical instability after healing. (6) Recurrence of the disease, and (7) Multiple vertebral involvement in children with severe kyphosis. The various techniques of surgical treatment are: (1) Costo-transversectomy, where there is a large abscess in the thoracic region. (2) Antero-lateral decompression for a paravertebral mass, either an abscess or granulation tissue. The technique is primarily an extra-pleural exposure of the abscess/granulation tissue and the vertebral lesion, and partial excision of the vertebral body so that the pressure on the cord is relieved. Normally, 2 or 3 ribs are removed for about 2 to 3 inches at their vertebral end. The intercostal artery and nerve are identified and ligated. The cord with its covering membranes should be exposed anteriorly and laterally so that pulsation of the cord commences after the decompression. The vertebrae are then fused with the resected ribs. This is the commonest procedure used in this country. (3) Transthoracic anterior decompression, in which the rib is excised at the maximum diameter of the abscess below the 5th dorsal vertebra on the left side, and above the 5th dorsal vertebra on the right side. The intercostal artery is ligated beyond the origin of retrograde spinal arterial branches, taking particular care to preserve the 9th left intercostal artery. Pleura is then opened. The ribs are separated, after allowing the lung to collapse. The abscess is located intrapleurally and confirmed first by aspiration of its content. The abscess cavity is then opened by a cruciate incision, the abscess

evacuated, granulations tissue and vertebral body excised till a pulsating cord is demonstrated. The vertebral bodies are then fused with the excised ribs. In the cervical spine, an abscess in the C,-C2 region is normally retropharyngeal and a transoral evacuation is necessary. Below the C2 level, an abscess of the cervical spine is evacuated through an approach centred on the posterior margin of the sternomastoid muscle. Ligation of the branches of the external carotid artery may be necessary. The trachea and oropharynx are identified, retracted medially, the longus colli and anterior vertebral muscles identified after longitudinal division of the prevertebral layer of the deep cervical fascia and the abscess evacuted. Diseased vertebral body is excised to normal bone; the pulsations of the cord are confirmed, and then fusion is done using an iliac graft. In the lumbar spine, evacuation of the lumbar abscess is done through Petit's triangle or by means of renal approach or through a retroperitoneal sympathectomy approach. A psoas abscess is evacuated through the external abdominal muscle parallel to the hypogastric or ilio-inguinal nerves. Laminectomy is indicated only if there is post element disease with cord compression. Anterior spinal fusion is done in all cases where an anterio-lateral or a trans-thoracic decompression has been done. Post spinal fusion, as recommended by Hibbs28, is done in children to prevent excessive kyphosis, ,and where there is multiple segmental vertebral involvement. No instrumentation should be done in such cases. Post operative care in all the cases should be a protective plaster jacket or a moulded orthoplast brace for about 4 weeks. An adequate supportive brace is necessary till bony fusion has occurred.
(B). Tuberculosis of Sacro-iliac Joint

Tuberculosis at this uncommon site is frequently missed. Tenderness over the sacroiliac joint and compression and distraction tests are painful. There could be either sacral or iliac lesion. The cold abscess can be either intra pelvic or under the gluteus maximus muscle. Diagnosis is established by aspiration of pus or a fine needle aspiration biopsy. Antituberculosis therapy and protective bracing are the treatment of choice. Where .there is extensive obstruction, exposure of

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the sacro-iliac joint, as advocated by Smith Patersen is done followed by fusion of the joint after curettage of all infected bone and cartilage. (C). Tuberculosis of Hip Joint Involvement of the hip joint is the second commonest skeletal lesion, next to that of spine. It can occur in any age group but is more common in children. The clinical presentation is primarily a painful hip limp. In early stages, when there is an effusion in the joint, the affected limb is flexed, abducted and externally rotated, with an apparent lengthening of the extremity. In late stages, when destruction has been progressive, the limb goes into flexion, abduction and internal rotation, with an apparent limb shortening. If a pathological dislocation occurs, as a result of gross destruction of the femoral head or the superior acetabular margin, the hip is dislocated posteriorly and superiorly with true shortening of the involved limb. The femoral triangle can be full and an abscess may be palpable. Abscesses in the hip joint normally present themselves in the femoral triangle, but can present on the medial aspect of the thigh. Laterally, it can take the course of the femoral nerve, or posteriorly under the gluteus maximus muscle. External iliac lymphadenopathy is normally present, sometime with caseating lymphnodes. The clinical stages of the disease can be synovitis, early and advanced tuberculous arthritis with involvement of the articular cartilage and bone, and ultimate pathological dislocation. The anatomical sites of the lesions could be (a) the superior rim of the acetabulam, which is drained by the communicating venous channels of the Batson's prevertebral venous plexus and (b) Babcock's triangle limited by the inferior neck of femur, medially by the epiphysial line or equivalent stress lines in adults and laterally by the stress trabeculae of the neck of the femur which is intraarticular in location. Skeletal lesion can occur in the head and neck of femur, in the greater trochanter. Rarely, the lesion could be purely synovial in location. Differential Diagnosis Tuberculosis of hip has to be differentiated from transient synovitis of the hip, Legg Berthes

Halve disease, osteomyelitis of upper end of femur, acute infective arthritis of infancy and childhood osteoid osteoma of the neck of the femur with synovial involvement, rheumatoid arthritis, avascular necrosis of the head of the femur secondary to coronary disease or cortisone induced avascular necrosis. The diagnosis is best established by aspiration of the joint for a cold abscess or needle aspiration biopsy of synovial membrane. Rarely, a malignant synoviona of the hip joint can be mistaken for tuberculosis of the hip. Treatment Treament of hip joint comprises : (1) Rest in the acute phase, with skin traction to ease the spasm in the initial stages followed by hip spica to prevent mobility of the joint. (2) Anti-tuberculosis treatment, as discussed. If there is sequestration, or doubt in the diagnosis, open biopsy and sequestrectomy is desirable. If there is marked synovial thickening, as evidenced by radiological finding, a synovectomy of the hip joints is of value. In India, because of the deformity that is frequently present, the most useful method of treatment is Mac Murray's defunctioning inter-trochanter medial displacement osteotomy. In selected cases, in men, a hip intraarticular arthrodesis with total excision of the focus and articular cartilage may be necessary. (D). Tuberculosis of Knee Joint Tuberculosis of knee joint can occur in any age group. The most common symptoms are : pain on movement of the knee joint, synovial effusion, palpable synovial thickening and restriction of mobility. Tenderness may be present in the medial or lateral joint line and patello-femoral segment of the joint. In advanced cases, there is triple dislocation of the knee : lateral, posterior, and superior displacement of tibia on femur. The lesion is quite frequently synovial in location, with villi formation. Purulent material can accumulate in the joint space; destruction of articular cartilage secondary to the synovitis and metaphysial and subarticular lesions can occur, both in femur and tibia. Diagnosis is established by radiological examination which can show destructive lesions in the

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femoral or tibial condyles. Biopsy of the synovial membrane and aspiration of the joint fluid followed by smear, culture and guinea pig inoculation can confirm the diagnosis. Differential Diagnosis : Comprises internal derangement of the knee, pigmented or apigmented villio-nodular synovitis, haemophilic arthropathy of the knee, osteo-chondritis desicans of the articular surface of femur, rheumatoid arthritis of the knee joint, osteo-arthritis of the knee joint and synovial sarcoma. Treatment: Comprises anti-tuberculosis regimens as given for other tuberculous lesions of bones and joints combined with postoperative immobilization. Synovectomy and joint debridement, if done early, give good results. When extensive articular destruction is present, Charnley's29 compression arthrodesis of the knee is the treatment of choice. Though total knee replacements have been done for tuberculosis of the knee, long term follow ups have not been reported.

lesions very similar to tuberculous lesions can occur in Madurella madurella infection. Differential diagnosis should include a neuropathic change in the foot, secondary to diabetes or leprosy. Treatment : Anti-tuberculosis regimens, as for the other forms. Foot lesions are most amenable to curettage and immobilization. A triple arthrodesis is the ideal procedure for lesions of the talo-navicular, calcaneo-cuboid or talo-calcaneal lesions. An isolated navicular lesion can be treated by excision of the navicular bone. Post-operative immobilization, with foot in the plantigrade position is essential in all cases. Tuberculous dactylitis can be curetted out with adequate sequestrectomy.

(G). Tuberculosis of Upper Extremity

The shoulder involvement is rare, occuring mostly in adults. The classical sites could be head of humerus, glenoid, spine of the scapula, acromio-clavicular joint, coracoid process and synovial lesion. It can also be iatrogenic : steroid injection given for a stiff shoulder with the mistaken diagnosis of frozen shoulder, particularly in diabetics. The clinical presentation is with severe painful restriction of the shoulder movements, particularly abduction and external rotation, and gross wasting of shoulder muscles. There is an atrophic type of tuberculosis of the shoulder, called caries sicca. Differential Diagnosis : Comprises peri-arthritis of the shoulder, rheumatoid arthritis and post traumatic shoulder stiffness. Aspiration of the shoulder and fine nee,dle aspiration biopsy might be necessary to establish the diagnosis. The patient responds well to anti-tuberculosis regimens. A shoulder spica in the position of function is necessary in the younger age groups. Shoulder arthrodesis is rarely necessary and if one is done, it is restricted to the right shoulder only.

(E). Tuberculosis of Ankle Joint

The most common sites of lesions are tibia, fibula and talus. Clinical symptoms are the same as for other joint lesions : swelling, synovial thickening and pain on movement. Osteochondritis desicans of talus can simulate a tuberculous lesion of the ankle. The treatment of choice is antituberculosis drugs. Plaster of Paris immobilization, and arthrodesis at 95 planter flexion after debridement in adults are ideal.

(F). Tuberculosis of Foot

The foot bones can have isolated tuberculous lesions as in the os calcis or as diaphysial foci in metatarsal bones (tuberculous dactylitis). A subchondral lesion in the os calcis leading to talocalcaneal arthritis and peroneal spastic flat foot is a definite clinical entity. Talo-navicular and naviculo-cuneiform lesions and calcaneocuboid joint involvement can also occur, particularly in diabetes mellitus. The tarso metatarsal articulation at Lisfranc's level and the metatarso phalangeal joint of the great toe can be other foci of involvement. Signs and symptoms are pain, swelling, rigidity of foot and swelling of the metatarsus. Rigid peroneal spastic flat foot has to be excluded. Foot

(H). Tuberculosis of Elbow

The most frequent sites of involvement are medial and lateral condyles of the humerus, articular surface of olecranon-intra articular (but occasionally extra articular) and head of radius. Synovial thickening of the radio-humeral segment of the articulation can be normally felt, particularly if the synovium is involved. X-ray examination is highly suggestive. A pathological dislocation of elbow is very rare. The diagnosis can be con-

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finned by aspiration or biopsy of synovium from the lateral side. In differential diagnosis, I have seen a case of osteochondritis desicans of the humeral condyle and an osteoid-osteoma of the lateral condyle of the humerus, intra-articular in location, being mistaken for tuberculosis of the elbow joint. Treatment : Anti-tuberculosis regimes, as prescribed for musculo-skeletal lesions and immobilization in a functional position during early treatment. Synovectomy, joint debridement, excisional arthroplasty of elbow with distraction of the excised surface using an external fixateur (Ognasian) has been advocated. Simple excision of the elbow gives satisfactory results though there is lack of stability of the elbow.
(I). Tuberculosis of Wrist

lous osteomyelitis can also occur in odontoid process, spine of the scapula, ischium and fibula, but the diagnosis is frequently missed. Disseminated lesions may also present as bone cysts. A firm diagnosis can only be established by biopsy of the lesion. Antituberculosis regimens with curettage of the lesion are the treatment of choice. (L). Tuberculosis of Tendon Sheaths & Bursae

The anatomical sites of the lesions may be in the radius or proximal row of carpal bonesscaphoid, lunate and capitate. Concomitant involvement of the sheaths of volar or dorsal tendons might occur. The differential diagnosis is rheumatoid arthritis of the wrist. Biopsy of the wrist can be easily done from the dorsal route. Anti-tuberculosis regimens along with plaster of Paris immobilization (a scaphoid type of plaster) in position of function are recommended till the acute episode subsides. An arthrodesis of the wrist in 10 dorsiflexion gives very good result.
(J). Tuberculosis of Short Bones Tuberculosis of the metacarpus, metatarsus, and phalanges is common. They quite frequently present as marked swelling on die dorsum of the hand and soft tissue abscess is normally a common feature. Chronic pyogenic osteomyelitis, leutic osteitis and mycotic lesions in the foot bones have to be differentiated. Debridement and antituberculosis regimen result in complete subsidence of the lesion. (K). Tuberculous Osteomyelitis Tuberculous ostemomyelitis occurs in about 3% of patients with bone and joint tuberculosis. In 7% of them, the skeletal site of lesion is multiple. The most frequent sites are : manubrium sterni, sternum and isolated spinous processes. Tubercu-

Antituberculosis regimes coupled with excision of the synovial sheath and bursae are the treatment of choice. The spread to these sites is normally from the neighbouring bone or joint but it could be due to haematogenous spread. It can also occur from gravitational spread of the disease from the diseased area. The most significant clinical feature is crepitus due to melon seed bodies which are agglutinated protein nodules nurtured by the synovial fluid.
Acknowledgements

Any tendon sheath or bursa can be involved in tuberculosis. The commonest sites are flexor tendon sheaths of hand, subacromial bursa, olecranon bursa and bursae under the medial head of gastrocnemius. In the volar aspect of the wrist, the classical presentation is a dumb-bell shaped swelling giving cross fluctuation and crepitus.

This oration would have been impossible to give without the help of Prof. B.K. Dhaon of the Lok Nayak Jai Prakash Narain Hospital who gave me his invaluable time and material for making the entire package. To Dr Mathew Varghese of St. Stephens Hospital, I owe a deep debt of gratitude for providing me with clinical photographs and clinical slides for presentation.
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