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P.5.C. cells
*ne"trophyl+
soon replaced y *28 hrs+
5acrophages *monon"clears+
Phagocytose t acil
&ransform into
'pithelioidcells n"mers f"sion giant cells *m"ltin"clear+
1 week later
s"rro"nded y lymphocyte cells
ring *corona+ mass I Cod"le
I hard &K$'(D/' grows y e4pansion and coalescence
2 weeks
caseation in the center
I soft &K$'(D/'
Tuberculosis
1ip <oint
)nee <oint
=ertera
Hoint *hip3 knee3 etc+
Primary lesion : l"ngs3 *mediastinal+ lymph nodes which is active3 !"iscient or
latent spreading : vasc"lar
&-acil infects
A
tuberculosis of bone and joint/SKN-06
o %ynovial tiss"e
o or s"chondral one same vasc"lariLation
o or oth
o >ran"loma
%ynovial e4"date pann"s cartilage n"trition destroy the
cartilage
%"chondral *synov.one <"nction+ detach the chondral
layer
o Dartilage lesion from periphery. '4"date : no proteolytic enLyme
*compare : s"pp"rative+
o Dentral 9.$. area preserve for many years *f"nction+
o $y eEective &4 : good f"nction
Infection in metaphysis :
o >rowth plate : has no arrier f"nction can e penetrated y the t
process <oint space
Mscess *cold+ spreads sin"s 0 2
nd
ary infection
%pine t
o the most common J .:?
o ma<or location : &8-/A
o least common : D1-D2
o 2 or A verterae may e involved
o 2 diEerent lesion may occ"r
o primary lesion : l"ngs3 lymphnodes *mediastinal3 mesentary3
cervical+3 kidney3 other viscera *active3 !"iscient3 apparent or latent+
o spreading :
vasc"lar :
arteri : acteriaemia
veins : ple4"s of $atson
lymphogen : anatomic levels F. : )idney t-/
direct
o A pattern of involvements :
1. central type : $atson6s ple4"s
2. paradiscal type : vasc"lar
A. anterior type : ascess e4tension
Spreading of the %ertebral abscess
5arked e4"date
reaction
2
Dold
ascess
corp"s
tuberculosis of bone and joint/SKN-06
paraverteral anterior
ascess posterio
interverteral disc
necrosis
n"trition
dist"red
%preading3 e4tention
prop"lsion3 retrop"lsion
y compression of 2 verterae
(uture course of tb spine
1. may resolve completely
2. the lesion walled oE3 caseo"s tiss"e calciFed
A. low grade chronic Fromato"s gran"lating ; caseating
2. local spreading or systemic spreading
1ealing
1. Firo"s healing gives widegap
2. $ony ankylosis :
in children
in ad"lt *after chemo &4 in given+
"omplication
1. ascess spreading
2. %coliosis
A. )yphosis
2. Paraplegia *spinal cord lesion+
)adiology
DlassiFcation *David-Dha"sse+3 17,7
%tage I
%ynovial onset :
o Co ony lesion
o DiE"se osteoporosis *rarefaction+
o Hoint space : widening J
%tage II
$ony onset :
o H"4ta artic"lar one : erosionGcavities
o Hoint space decrease
%tage III
9hole <oint involved
o Mnatomical appearance J C
o $ony cavities
8
Paradiscal
t-
process
longit.lig.
tuberculosis of bone and joint/SKN-06
o Hoint space disappear
o %evere demineraliLation
%tage I=
9orsening of all stage III
o >ross anatomical appearance is poor
o %tage III J I= : adly washed 4-ray# : severe osteoporosis and soft
tiss"e swelling interposition
o If necessary tomogram
*aboratory
no diagnostic val"e
'%(3 le"co3 lympho 0 no help in disting"ishing pyogenic or speciFc process
traditionally : '%(3 le"co : C3 P5C : C3 lymphocytes
%kin t"erc"lin test 7,? J
D"lt"re otained from
o $iopsy :
aspirationGneedle iopsy
arthroscopy
open
N-ray of the l"ng and "rine *t of &r.K>+ ro"tinely e4am.
Bacteriology
acid fast
scarcely in one ; <oint
strictly aeroic organism
o needs B
2
to m"ltiply Op"lmonary t : rich B
2
many acilsP
m"ltiplication :
o B
2
needed
o P1 ne"tral
dormant acteria
microscopic e4am J 11? *J+
2 diEerent acterial pop"lation
*5itchison ; Dicknison+ 17,8
*ung lesion Bone + Joint
*esions
,cti%e drugs
)-(.'/,
Dontino"s act
growth
Dontino"s act
growth
J
Intermittent Intermittent J
; slow growth act ; slow growth act J
Dormant act Dormant act Q
$iagnosis
1. PM : soft t"ercle : gran"loma J caseo"s
2. PM : hard t"ercle J clinical signs J (adiology
A. D"lt"re
1ard t"ercle : gran"loma witho"t caseo"s *noncaseating gran"loma+
.
tuberculosis of bone and joint/SKN-06
a. t"erc"loid leprosy
. cocydidiomycosis
c. atypical mycoateria
d. erythema nodos"m
e. tra"matic fat necrosis
f. r"cellosis
g. gran"loma ca"sed y contamination
- Lirconi"m
- erylli"m
- corp. Mlien"m giant cell reaction
- hydatic deris
- Drown6s disease
- sarcoidosis
0eneral 'rinciples of Treatment
>eneral3 chemotherapy3 local3 operative3 ascess
>eneral :
(est3 lieral diet3 hygienic s"rro"nding
"hemotherapy :
5ethod of choice3 most treatment
2 asic principles :
a. m"ltiple chemot43 sensitive to t-acil
. s"@cient period of time
&4 complience3 ma<or determant of &4. eEectivenes
%ome regiments
&raditional triple dr"gs
IC1G(IFGPR for 2 months
Dontin"ed IC1G(IF for *7-18+ months
%in"s *es+ present : road spectr"m antiiotic
Pyrido4in added to prevent to4ic eEect of IC1
or IC1G(IFGPR J ' or % for 2 months
Dontin"ed IC1G(IF for *7-18+ months
Dosis :
IsoniaLid *IC1+ : *1:-2:+mgGkg PB ma4 A::mgGday
(ifampicine *(IF+ : *1:-2:+mgGkg PB ma4 .::mgGday
PyraLinamide *PR+ : *18-A:+mgGkg PB ma4 2gGday
'tham"tol *'+ : *18-2:+mgGkg PB ma4 238gGday
%treptomycin *%+ : *2:-2:+mgGkg PB ma4 1gGday
*ocal T1
ImmoiliLation : plastering3 racing
5oiliLation : depend on the local condition3 to preserve cartilage3 (B53
m"scle tone
(ed"ction of deformity : traction3 plastering
(ehailitation
,
tuberculosis of bone and joint/SKN-06
2perati%e
Kmrella *1:-12+ days efore s"rgery
%hortened the d"ration of the desease
Dertain indications :
o e4tensive destr"ction of the process
o stage II3 *III+ clinically
o stage III3 *I=+ radiologically
o no or slow improvement y conservative &4
o large ascess
o cord compression
o kyphosis S A:
:
in children
Deridement3 synovectomy3 correct deformity3 preserve the >.P
,bscess
1. conservative
2. drainage : tension3 press"re
aspiration
incision
TB-3yphosis
Mng"lar deformity of spine
%erio"sness in children
Da"se :
o verteral ; disc damage
o Fro"s ankylosis
o d"ring healing process : s"<ected stress &h-&h-/ stress kyphosis
)yphosis in children : di@c"lt prolem
o may compromise visceral f"nction
cardio-respiratory prolem
paraplegia *internal gi"s+
o ad<acent spinal segments : compensatory hyperlordosis
o ri changes
o sternal deformity
o spontaneo"s posterior spinal f"sion
o may associated with paraplegia of healed desease with or witho"t
resid"al active disease
5edical (esarch Do"ncil in )orea *1788+
1.: children : &1 ; / kyphosis S 1:
:
at Frst e4am :
follow "p in 1: years3 increase in kyphosis
*1:
:
-A:
:
+ I AA ?
*A1
:
-8:
:
+ I 1,?
8
tuberculosis of bone and joint/SKN-06
*81
:
-,:
:
+ I.?
no change I A.?
decrease I 8?
ImmoiliLation does6nt arrest the anatomical damage
Degree of kyphosis depends on :
1. Initial kyphosis3 n"mer of verteral involved
2. location of kyphosis3 &h3 &h-/
A. age of onset
2. lack of ony f"sion
8. vasc"lar factor of growth plate
&reatment of kyphosis
'arly detection and treatment
SA:
:
radical s"rgery *1odgson+
J posterior arthrodesis
)eference
1. Mpley M>3 %olomon / : Mpley6s %ystem of Brthopaedics and Fract"res ,
th
'd
*p.2,-8:+. $"tterworth 1einemann3 177A
2. Davidson PF3 Fernendes ': $one and Hoint &"erc"losis3 %chlosserg D *'d+
%pringer 0=erlag3 $erlin3 1788
A. D"thie ($3 $ently > : 5ercer6s Brthopaedic %"rgery 7
th
'd *p..:2-.A2+
MrnoldGB4ford Kniversity Pres3 Cew Tork3 177.
2. 5artini3 5 : &"erc"losis of the $ones and Hoints. %pringer-=erlag3 $erlin3
1788
8. &ach<ian 5D. Pediatric Brthopaedics.2
nd
'd-=ol 2 *p.122A-12.1+3 $.$.
%a"nders3 177:
.. &"li % 5: &"erc"losis of the %pine. Mmerind P"l. Do. Cew Delhi3 17,8
7