Copyright 1996 by The Journal of Bone and Joint Surgery, Incorporated
Current Concepts Review
Tuberculosis of Bones and Joints*
BY HUGH G. WATTS, M.D.t, LOS ANGELES, CALIFORNIA, AND ROBERT M. LIFESO, M.D4, BUFFALO, NEW YORK
The prevalence of tuberculosis15 in the United States
has been rising since 1986, with morbidity increasing
14 per cent from 1985 through 1993. In 1986, the rate
of tuberculosis in the United States was 9.3 new cases
per 100,000 population. In 1991, the rate in New York
State'213 had risen to 17.3 per 100,000, and the rate in
central Harlem was 169 per 100,000, which is similar to
rates reported in the eastern and central regions of Af-
rica712. Much of this increase has been in the rate of
pulmonary tuberculosis, but it has been associated with
a concomitant rise in the number of adults and chil-
dren who have tubercular musculoskeletal involvement.
In a prospective study of a cohort of intravenous drug
abusers in New York City who tested positive with the
tuberculin skin test, the risk of active tuberculosis was
14 per cent (seven of forty-nine patients) a year during
a two-year follow-up interval76. It is becoming increas-
ingly likely that an orthopaedic surgeon who works in a
developed region of the world (especially in a big city)
will encounter a patient who has tuberculosis, a disease
with which the surgeon may have little experience or
training13.
Factors that have contributed to the increased rate
of tuberculosis are the rise in the number of people
who have suppression of the immune system, the devel-
opment of drug-resistant strains of Mycobacterium, an
aging population, and an increase in the number of
health-care workers who are exposed to the disease. The
human immunodeficiency virus remains the leading
known risk factor for the reactivation of latent tuber-
culous infection656879, and patients with this virus who
are exposed to Mycobacterium tuberculosum are more
likely to have progression to an active disease state than
non-infected patients.
Tuberculosis is an ancient disease. Spinal tubercu-
losis has existed for at least 5000 years38, and mum-
mified remains from northern Egypt dating from 3400
B.C. provide strong evidence of its presence38. The first
known description of tuberculous spondylitis was writ-
ten in Sanskrit sometime between 1500 and 700 B.C.3890.
*No benefits in any form have been received or will be received
from a commercial party related directly or indirectly to the subject
of this article. No funds were received in support of this study.
tShriners Hospital for Crippled Children, 3160 Geneva Street,
Los Angeles, California 90020.
JErie County Medical Center, 462 Grider Street, Buffalo, New
York 14215.
288
Tuberculosis, or "consumption," has paralleled the
socioeconomic rise and fall of humankind. In the late
eighteenth century, Pott noted the association between
tuberculous involvement of the thoracic spine and para-
plegia61. By the beginning of the twentieth century, tu-
berculosis was the leading cause of death in Western
society2445. In the era before antitubercular drugs were
available, patients for whom treatment in a sanitarium
setting was considered to be successful still had a 60 per
cent mortality rate within six years after discharge from
the sanitarium65.
The potential for control of tuberculosis with mod-
ern chemotherapeutic drugs has been shown among the
Eskimo population in Northern Canada. In 1950, the
rate of new infections was 25 per cent a year. By 1970,
however, the incidence of new infections was so low as
to be unmeasurable. This is a tribute to the effectiveness
of medical treatment, public-health authorities, and a
highly cooperative patient population17-31.
Three related organisms Mycobacterium tuber-
culosis, Mycobacterium africanum, and Mycobacterium
bovis are the causes of tuberculosis. Mycobacterium
tuberculosis is by far the most common. Mycobacterium
africanum is rarely found outside of Northwestern Af-
rica, and disease due to Mycobacterium bovis is limited
in developed countries by the widespread pasteuriza-
tion of milk65.
Mycobacterium tuberculosis is a thin rod with round
ends, 2.0 to 2.5 micrometers long. It is non-motile,
without a capsule, and is difficult to stain with use of
the usual methods. If it is stained with the classic car-
bol fuchsin or Ziehl-Neelsen method, it resists decolori-
zation with strong mineral acids and alcohol; hence,
Mycobacterium tuberculosis is considered an acid-
alcohol-fast or acid-fast bacillus. Its histological appear-
ance is small curved or straight rods of red or pink.
Mycobacterium tuberculosis does not grow on ordinary
culture medium; it grows only on enriched medium con-
taining an egg and potato base or serum (albumin) base.
It has a slow rate of growth, and grossly visible colonies
first appear at two to four weeks. Mycobacterium tuber-
culosis is a strict aerobe, and its rate of growth is highly
dependent on oxygen tension. When tension is high, as
in the tuberculosis cavity of the lung, Mycobacterium
tuberculosis multiplies freely. When tension is much
lower, as in the caseous foci of the lung, it multiplies
slowly or not at all.
THE JOURNAL OF BONE AND JOINT SURGERY
 T U B E R C U L O S I S OF BONES AND JOINTS
The World Health Organization has estimated that
one-third of the global population is infected with My-
cobacterium tuberculosis, and tuberculosis remains the
most frequent cause of death and disability on a world-
wide basis, accounting for close to three million deaths
each year1043. An estimated ten million persons are pres-
ently infected with Mycobacterium tuberculosis in the
United States, and 90 per cent of new activated cases
come from this infected pool of individuals76.
In non-Hispanic white people, the median age at
diagnosis is sixty-one years6. Among American minority
groups, tuberculosis is primarily a disease of younger
people, with a median age at diagnosis of thirty-nine
years6. Americans who are more than sixty-five years
old account for 6.5 per cent of the United States popu-
lation but account for 26 per cent of the total number
of reported cases of tuberculosis"-68.
When the prevalence of tuberculosis in a commu-
nity is high, most of the population in that community
has been infected by the age of twenty years. When the
prevalence of tuberculosis in a community is low, almost
all clinically infected patients are more than fifty years
old and probably were infected years earlier and are
showing signs of reactivation of the disease3031. Reported
cases13 of tuberculosis in American children less than
fifteen years old declined from 6036 in 1962 to 1177 in
1986. This number increased 36 per cent, to 1596 pa-
tients6, in 1987.
In the United States, one-fifth of diagnosed new cases
of tuberculosis are associated with extrapulmonary dis-
ease12. About one-third of patients with tuberculosis
who are also infected with the human immunodeficiency
virus will have extrapulmonary disease with or without
a pulmonary component586775.
Tuberculosis has been reported in all bones of the
body636. In the United States6, the spine is involved in 50
per cent of patients (the thoracic spine in 50 per cent, the
cervical spine in 25 per cent, and the lumbar spine in 25
per cent); the pelvis, in 12 per cent; the hip and femur, in
10 per cent; the knee and tibia, in 10 per cent; the ribs, in
7 per cent; the ankle or shoulder, in 2 per cent; the elbow
or wrist, in 2 per cent; and multiple sites, in 3 per cent.
Extrapulmonary tuberculosis is more common in
children than in adults, and about one-third of children
who have tuberculosis have extrapulmonary manifes-
tations, the most common being involvement of the su-
perficial lymph nodes (scrofula)80. Involvement of the
cervical spine is rare in children1381. The infecting organ-
ism is usually Mycobacterium tuberculosis, but it may be
Mycobacterium bovis or even Mycobacterium kansasii,
Mycobacterium fortuitum, Mycobacterium marinum, or
Mycobacterium intracellulare.
Diagnosis of Tuberculosis in Bones and Joints
Clinical
The clinical presentation of musculoskeletal tuber-
culosis includes localized pain associated with fever and
VOL. 78-A, NO. 2, F E B R U A R Y 1996
289
weight loss. If the spine is involved, truncal rigidity, mus-
cle spasm, and neurological signs may be present. A
cold abscess (swelling without inflammation) is strongly
suggestive of musculoskeletal tuberculosis. Although a
skeletal lesion may be the presenting symptom complex,
any individual who has a skeletal lesion that is suspected
of being tuberculous must be evaluated for the possibil-
ity of other involved sites, including the lungs, intestinal
tract, and kidneys77. Only about one-third of patients
who have tuberculosis of a bone or joint have a history
of pulmonary disease18. The diagnosis is sometimes more
difficult to make in elderly individuals in whom the
presentation of the disease often involves non-localized
constitutional symptoms.
Plain Radiographs
There are no specific radiographic features that
are pathognomonic of tuberculosis of bones or joints.
Common findings that should arouse suspicion of joint
involvement include osteopenia, soft-tissue swelling
with minimum periosteal reaction, narrowing of the
joint space, cysts in bone adjacent to a joint, enlarge-
ment of the epiphysis in children, and subchondral
erosions involving both sides of the joint358489. (These
erosions cross the epiphysis in more than one-third of
affected children.)
Features in the spine include rarefaction of the ver-
tebral end plates, soft-tissue abscess, increasing loss of
disc height, variable degrees of osseous destruction, and
new-bone formation. Often, multiple bones are involved
in the spine, and late fusion or collapse of bone is not
uncommon. Radiographic findings in patients who have
disease related to the human immunodeficiency virus
may be caused by other diseases and should not be
automatically ascribed to tuberculosis.
Bone Scan
There are no specific scintigraphic features of tuber-
culosis that are pathognomic. In one study of fifty-six
patients who had a tuberculous lesion, technetium-99m
bone scans showed diffuse changes in uptake similar
to those seen with metastatic disease in thirty-five pa-
tients (63 per cent), and the scans proved to be negative,
or so-called cold, in the presence of active disease in
twenty-one (38 per cent)89. The negative scans may rep-
resent avascular segments of bone due to the formation
of an abscess. Indium-ill-scanning is non-specific but
may show decreased activity in bone marrow55.
Skin Test
After his discovery of the tubercle bacillus, Koch
found that a concentrated filtrate from culture speci-
mens of Mycobacterium tuberculosis that had been
killed with heat protected guinea pigs from experimen-
tal tuberculosis. He called this material tuberculin. In
the 1930's, precipitants of tuberculin were developed,
and this precipitated material was called purified protein
290 H. G. WATTS AND R. M. LIFESO
derivative75. Essentially, purified protein derivative con-
tains a number of components that are antigenic to the
tubercle bacillus. At the turn of the century, approxi-
mately 90 per cent of the population reacted in some
way to the injection of tuberculin. Interpretation of the
results of the tuberculin or purified-protein-derivative
skin test depends on the prevalence of exposure to tu-
berculosis, immunosuppression, or the possibility of
previous vaccination with bacille Calmette-Guerin. At
present, the general adult population of the United
States has a rate of infection of 5 to 10 per cent, and the
positive predictive value of the tuberculin test is begin-
ning to decrease when applied to this population. At least
20 per cent of debilitated or malnourished patients who
have extensive disease have a false-negative skin test70.
Similarly, patients who are co-infected with the human
immunodeficiency virus and tuberculosis are prone to
anergy and negative skin-testing, especially in the later
stage of acquired immunodeficiency syndrome5769.
In our experience in Saudi Arabia, the rate of con-
version to a positive tuberculin test was 10 per cent per
decade. In other words, at the age of seventy years, 70
per cent of the population whom we tested had conver-
sion to a positive tuberculin test without overt manifes-
tations of tuberculosis.
Other Tests
General tests of inflammation, such as measurement
of the erythrocyte sedimentation rate, are neither spe-
cific nor completely reliable. Serological testing, espe-
cially the ELISA (enzyme-linked immunosorbent assay)
test, has a reported sensitivity of 60 to 80 per cent1659, but
these tests may be negative for patients who have ad-
vanced disease. New work in chromatography, nucleic
acid probes, and polymerase chain reaction in addi-
tion to nucleic acid probes by systems using antibodies
against Mycobacterium tuberculosis are gradually being
introduced, but at this stage they have not been tested
extensively and are not widely available59667'7274.
In regions where brucellosis is endemic, a Brucella
complement-fixation test should be performed as bru-
cellosis can mimic tuberculosis clinically. (We are aware
of one patient who had proved brucellosis and proved
tuberculosis at different levels of the spine.)
Culture
The ultimate diagnosis of tuberculosis depends on
the recognition of Mycobacterium tuberculosis on either
histological study or culture, or, ideally, both. Because of
the frequency of associated tuberculosis in the lungs and
kidneys, culture of specimens of sputum and urine can
be helpful91, but these tests are often not performed on
orthopaedic patients.
Biopsy
In countries where tuberculosis is highly preva-
lent and where medical facilities are limited, patients
who have clinical symptoms and radiographic findings
suggestive of the disease may not need to have a bi-
opsy of the lesion in order for the physician to make a
diagnosis and to institute treatment. Ideally, the preva-
lences of resistant strains and of other diseases that can
mimic tuberculosis are known and can be excluded with
the use of other modalities (such as the complement-
fixation test for brucellosis). In this setting, biopsy and
possible operative treatment are reserved for patients
who fail to respond to adequate chemotherapy, who
have substantial neurological impairment, or in whom
either resistant strains or other disease entities are sus-
pected. In these areas of endemic disease, it is important
that the prevalence of disease and of antibiotic resis-
tance be known and documented.
In areas where the disease is not prevalent or where
strains that are resistant to multiple drugs are common,
biopsy is mandatory, both to make the diagnosis and
to determine antibiotic sensitivity. We recommend the
initiation of antituberculosis treatment at the time of
the biopsy to decrease the likelihood of dissemination
of the disease during that procedure. This is most im-
portant when the infection may involve the central
nervous system and when there is a high index of suspi-
cion, either because of a high prevalence of endemic
disease or because active tuberculosis has been sug-
gested on the basis of the clinical history or the findings
on frozen section. In these clinical circumstances, we
use triple or quadruple-drug therapy if multiple-drug-
resistant tuberculosis is suspected. For biopsies per-
formed in areas where the disease is not endemic and
for those performed percutaneously and thus associated
with only a slight risk of contamination, we consider
empirical antituberculosis treatment on a patient-by-
patient basis.
If a biopsy specimen is taken from a joint, tissues
from adjacent cystic lesions and synovial tissue should
also be obtained and sent for both histological study and
culture. Simple aspiration of the joint is much less likely
to lead to a definitive diagnosis29-89. In the spine, com-
puted tomography-guided needle biopsy usually yields
sufficient material either from the spine itself or from
an adjacent abscess. Open biopsy of the spine is usually
reserved for occasions when either closed techniques
have proved insufficient or other procedures, such as
decompression and possibly arthrodesis, are contem-
plated. Stains for acid-fast bacilli, fluorochrome, and
the traditional Ziehl-Neelsen stain are relatively rapid
and inexpensive but may produce false-negative results.
Stains to identify acid-fast bacilli reliably require the
presence of at least 10" acid-fast bacilli per milliliter of
specimen70, but cultures are more sensitive and can reli-
ably identify mycobacteria in a concentration of 103 or-
ganisms per milliliter of specimen28. Drug-susceptibility
testing is possible with cultures. The major drawbacks
are that conventional culture techniques are slow, re-
quiring weeks before a positive result for Mycobac-
T H E J O U R N A L OF BONE A N D JOINT SURGERY
 T U B E R C U L O S I S OF BONES A N D JOINTS
terium tuberculosis can be identified, and at least a mod-
erately well equipped laboratory is needed.
Limiting the Spread of Tuberculosis
in Health-Care Facilities
As the prevalence of tuberculosis increases, the per-
ceived or real threat to health-care workers requires
consideration. Any patient who is suspected of hav-
ing active infectious pulmonary tuberculosis should be
placed in a tuberculosis isolation room with the appro-
priate ventilation facilities21. Ideally, operative inter-
vention should be delayed until the patient is no longer
infectious. Respiratory precautions should be applied,
as should universal blood and body-substance pre-
cautions. The use of bacille Calmette-Guerin vaccina-
tion for health-care personnel working in areas with
a particularly high prevalence of tuberculosis is still be-
ing debated. The consensus is that the advantage of
possible protection does not outweigh the loss of the
use of the purified-protein-derivative tuberculin skin
test to indicate when a health-care worker has conver-
sion from a negative to a possibly positive infectious
status16.
Medical Treatment of Musculoskeletal Tuberculosis
The treatment of musculoskeletal tuberculosis is
primarily medical. Operative intervention is an adjunct
to appropriate antituberculosis chemotherapy. Each
year, the United States Centers for Disease Control
change their recommendations as to the exact combina-
tions, doses, and durations of drug treatment depending
on the incidence and resistance patterns of the locally
predominant strains of Mycobacterium tuberculosis. As
a result, medical treatment can only be summarized with
generalities. If the need to provide tuberculosis therapy
is infrequent, we recommend that the Centers for Dis-
ease Control be contacted for their most recently up-
dated guidelines. We also recommend consultation with
an infectious-disease specialist.
Successful medical treatment of tuberculosis re-
quires the prolonged administration of a minimum of
three drugs to which the organisms are susceptible, and
at least one of these drugs must be bactericidal. Because
of the spontaneous emergence of drug resistance in a
small number of tubercle bacilli, monotherapy with
even the most potent bactericidal drug (isoniazid) may
result in the selection of a resistant bacterial population
and lead to failure of the treatment and to acquired drug
resistance. .Therefore, a combination of drugs is neces-
sary to treat tuberculosis effectively. Prolonged drug
therapy is necessary to eliminate or sterilize so-called
persistent bacilli, which are small populations of meta-
bolically inactive organisms.
The following are considered the most effective
drugs at this time for the treatment of tuberculosis141921'33.
Isoniazid is the most potent bactericidal drug avail-
able and is particularly effective against actively growing
VOL. 78-A, NO. 2, F E B R U A R Y 1996
291
organisms. It is relatively non-toxic, easily administered,
and inexpensive. The usual adult dosage of three to five
milligrams per kilogram of body weight a day pene-
trates well into all bodily fluids and cavities. Hepatic
toxicity is a major side effect. Patients who have a history
of excessive alcohol consumption or hepatitis infection
have an increased probability of isoniazid hepatotoxicity.
Peripheral neuropathy caused by the interference of
isoniazid with the metabolism of pyridoxine is uncom-
mon at this dosage, although it may be a substantial
problem in persons with conditions that predispose them
to neuropathy, such as diabetes or alcoholism. Ten milli-
grams of pyridoxine a day should be given in conjunction
with isoniazid.
Rifampin and pyrazinamide are the most effec-
tive sterilizing drugs, and they are specifically effective
against bacilli that are dormant and undergo periodic
bursts of activity. Rifampin is bactericidal for Mycobac-
terium tuberculosis at the usual adult dosage of ten mil-
ligrams per kilogram of body weight a day. The most
common adverse reaction is gastrointestinal upset, but
mild jaundice may also occur. Pyrazinamide is bacteri-
cidal for Mycobacterium tuberculosis as well. The dos-
age is generally twenty to twenty-five milligrams per
kilogram of body weight a day.
Ethambutol is bacteriostatic. Retrobulbar neuritis
is the most frequent and serious adverse effect, with
symptoms including blurred vision, central scomata, and
red-green color blindness. This complication is dosage-
related, and red-green color discrimination and visual
acuity tests should be administered before and during
treatment. The dosage is fifteen to twenty-five milli-
grams per kilogram of body weight a day to a maximum
of 1.2 grams a day, and administration is discontinued at
two to three months.
Streptomycin is bactericidal but must be given par-
enterally. The usual adult dosage is fifteen to twenty
milligrams per kilogram of body weight to a maximum
of one gram per day. Almost all streptomycin is excreted
by the kidneys and therefore it must be used with ex-
treme caution in patients who have renal insufficiency.
The most common serious adverse effect is ototoxicity,
usually resulting in vertigo. The total cumulative dose
should not be more than 120 grams. The potential for
increased toxicity, especially in elderly individuals and
in immunocompromised patients who are taking other
chemotherapeutic agents, must always be kept in mind.
Other drugs that are especially useful in the face
of multiple-drug-resistant organisms include ethion-
amide, cycloserine, kanamycin, capreomycin, and para-
aminosalicylic acid. All of these drugs may be more toxic
and less well tolerated than the first-line agents. Before
they are used, we recommend consultation with a spe-
cialist in the treatment of tuberculosis.
The quinolones (ciprofloxacin and ofloxacin) have
an in vitro activity against Mycobacterium tuberculosis,
but resistance frequently develops and their use is lim-
292. H. G. WATTS AND R. M. LIFESO
ited. The macrolide antibiotics also demonstrate in vitro
activity against Mycobacterium, especially against the
Mycobacterium avium complex; however, they do not
appear to have substantial activity against Mycobacte-
rium tuberculosis.
The current recommendation for treatment of adults
who have musculoskeletal tuberculosis, with or with-
out infection with the human immunodeficiency virus,
is 300 milligrams of isoniazid a day, 600 milligrams
of rifampin a day, and twenty to thirty milligrams of
pyrazinamide per kilogram of body weight a day (dis-
continued after two months)59192065. Ethambutol (or
streptomycin for children who are too young to be
monitored for visual acuity) should be included in the
initial regimen until the results of drug-susceptibility
studies are available, unless there is little possibility
of drug resistance, such as when there is less than 4 per
cent primary resistance to isoniazid in the community
and the patient has had no previous treatment with
antituberculosis medications, is not from a country with
a high prevalence of drug resistance, and has had no
known exposure to drug-resistant tuberculosis591965. Ten
milligrams of pyridoxine a day is given as prophylaxis
against possible isoniazid-induced neuropathy.
The optimum duration of treatment has been an
issue of considerable debate, and much of the informa-
tion now available concerns the treatment of pulmonary
disease. The short-course regimens (six or nine months)
may not be applicable to extrapulmonary tuberculosis,
specifically those with osseous involvement. We recom-
mend that treatment be continued for a minimum of
twelve months for osteoarticular involvement, extend-
ing to perhaps eighteen months for certain problems. If
isoniazid resistance is demonstrated, rifampin and eth-
ambutol should be continued for a minimum of twelve
months.
Children should be managed essentially the same as
adults, with the use of appropriately adjusted doses of
the drugs9.
Tuberculosis that is resistant to multiple drugs
that is, resistant to at least isoniazid and rifampin
presents a difficult treatment problem. Treatment must
be individualized, and consultation with an expert in
tuberculosis is strongly recommended.
Osteoarticular Tuberculosis
Tuberculosis of bones and joints often presents as
gradually worsening arthritis. This often involves a cold
abscess, with or without drainage. Systemic and pul-
monary symptoms are frequently absent, and the dif-
ferential diagnosis must include other possible causes
of septic osteoarticular disease, inflammatory arthritis,
and possibly internal derangement of the joint. Os-
teoarticular tuberculosis rarely involves more than one
joint, and this may help to differentiate tuberculous
septic arthritis from other types of polyinflammatory
disease. Generally, the radiographic changes of tuber-
culosis that affect large weight-bearing joints are slow
to develop compared with those of pyogenic infections,
and a reduction in the joint space is often a late occur-
rence36. Any synovial space, bursa, or tendon sheath may
be infected.
Magnetic resonance imaging generally shows large
intra-articular effusions, periarticular osteoporosis, and
gross thickening of the synovial membrane 4 . A differen-
tial diagnosis between tuberculosis and pyogenic arthri-
tis is difficult, and an accurate diagnosis usually requires
biopsy of synovial tissue and demonstration of the ap-
propriate organisms on either histological study or cul-
ture. Aspiration of synovial fluid is often insufficient to
make a diagnosis, and culture specimens from draining
sinuses are usually contaminated with other organisms27.
Tuberculous infections of the joints are usually more
flagrant and clinically obvious in adults than in children.
As a consequence, the diagnosis of osteoarticular tuber-
culosis in children is often more difficult and a delay in
treatment is not uncommon.
Pathological fractures are rare but can develop in or
adjacent to a tuberculous joint37. They can be treated
with standard techniques of fracture management, in-
cluding internal fixation. We recommend appropriate
and prolonged chemotherapy at the time of treatment
of the fracture, combined with radical debridement and
drainage of abscesses.
Operative Treatment
Knee
In the early stages of disease of the knee, before
there is substantial loss of bone or cartilage, operative
intervention is necessary only to drain large abscesses
and to obtain synovial tissue for biopsy23'. Synovectomy
is rarely indicated in the early stages, and a prolonged
course of adequate chemotherapy generally sterilizes
the joint. We use external immobilization only to correct
fixed deformities, as we believe that early motion is
necessary after adequate debridement. The long-term
prognosis depends on the extent of the disease at the
time of the initial presentation and the adequacy and
duration of chemotherapy39.
Arthrodesis and joint replacement have been advo-
cated in the later stages, when there is loss of the
joint space and osseous architecture8399'. We recom-
mend arthrodesis of the knee in young patients who
have severe destruction of the joint, marked loss of
soft-tissue stabilizers, and possible deficiencies in soft-
tissue coverage. Because tuberculosis rarely involves
multiple joints, the patient is usually able to compensate
with motion of other joints. We recommend radical
debridement of all avascular tissue and the juxtapo-
sition of viable cancellous bone at the time of the
arthrodesis.
Total knee arthroplasty after chemotherapeutic ster-
ilization of a tuberculous knee joint is gaining in pop-
ularity2240. At a minimum, three months of adequate
T H E J O U R N A L OF BONE AND JOINT S U R G E R Y
 TUBERCULOSIS OF BONES AND JOINTS
chemotherapy is required to sterilize a joint, and only
then if all clinical and laboratory criteria suggest that
the joint is adequately sterile, should an arthroplasty
be considered. The arthroplasty must be followed by
a prolonged period of antituberculous chemotherapy92.
In a study of twenty-two patients who had had a to-
tal knee arthroplasty for tuberculous arthritis, Kim re-
ported a reactivation of infection in three who had
not had preoperative chemotherapy40. He thought that
a quiescent period of at least one year was necessary
before proceeding with total knee arthroplasty. We con-
cur that, in the appropriate patient who has active in-
fection, a two or three-stage total knee arthroplasty,
combined with adequate chemotherapy, is an excel-
lent procedure if the facilities are available. Eskola et
al.22 had similar findings and also stressed the importance
of chemotherapy.
Hip
Tuberculosis of the hip in adults presents a wide
spectrum of disease. In the early acute phase, with pres-
ervation of the joint space and osseous architecture,
a biopsy is often required to make the diagnosis and
to decompress the joint. If the articular cartilage and
osseous architecture are preserved, these patients do
well after a prolonged course of chemotherapy138. Exci-
sion arthroplasty remains an acceptable alternative in
some patients who have increased destruction of bone
and loss of articular cartilage. Unfortunately, these pa-
tients have an altered gait pattern, marked pain, and
shortening of the limb, but the disease can usually be
eradicated when an arthroplasty is combined with ade-
quate chemotherapy.
In patients who have evidence of destruction of the
joint and loss of articular cartilage, arthrodesis re-
mains an effective treatment. The indications depend on
the patient's occupation, the cultural milieu, and the
expectations of the patient and his or her family. For
patients who have complete destruction of the femoral
head, arthrodesis from the trochanter to the iliac wing
can be performed with use of standard internal fixa-
tion devices.
Low-friction arthroplasty has been recommended
as treatment for tuberculous septic arthritis of the
njp2i,4i.42,44.47 -j^g longest duration of follow-up of which
we are aware was in a report by Kim et al., who followed
sixty patients for eight to thirteen years42. They com-
mented on difficulty with exposure related to con-
tracted scar tissue and difficulty with wound-healing. Of
the sixty patients, three had reactivation of the tuber-
culosis, which was thought to be related to failure of
the patients to comply with the postoperative chemo-
therapeutic regimen. Total hip replacement without ce-
ment has also been used with apparently excellent
results23, but once again active chemotherapy must be
maintained for a prolonged period of time.
Our preferred method of treatment for active tuber-
VOL. 78-A, NO. 2, FEBRUARY 1996
293
culosis of the hip in which the joint space has been
destroyed consists of a radical decompression, drainage
of the abscess, and removal of all avascular tissue. This
is followed by high-dose antituberculosis chemotherapy
with multiple drugs until there is clinical and hemato-
logical evidence that the disease has been eradicated.
The second stage of treatment involves either an arthro-
desis of the hip in a young patient or a hip arthroplasty
without cement in an older patient. Again, these are
followed by a course of adequate chemotherapy.
Spinal Tuberculosis
Spinal tuberculosis presents a series of interrelated
problems. The disease begins in the anteroinferior por-
tion of the vertebral body and tends to spread beneath
the anterior longitudinal ligament to involve adjacent
vertebral bodies. Narrowing of the disc space occurs as
a late phenomenon when destruction of cancellous bone
on both sides of a disc allows the disc to herniate into
the affected vertebral body or bodies. Osseous infarc-
tion and osteonecrosis may lead to a decrease in verte-
bral height and may be accompanied by paravertebral
and possibly epidural formation of an abscess89. Because
the anterior portion of a vertebral body is involved
and the posterior portion is rarely involved, a sharp ky-
phosis may occur, and even with resolution of the acute
infectious process the kyphosis may continue to cause
anterior compression of the cord and late neurological
sequelae89. Multiple sites in the spine may be involved
simultaneously. In our experience, 5 per cent of patients
who were seen with neurological impairment had no
obvious discernible vertebral lesion; epidural abscess,
severe arachnoiditis, and intradural tuberculomas ac-
counted for these neurological lesions89. Spinal tubercu-
losis has often been called the great imitator because its
radiographic appearance may mimic other pathological
conditions affecting the spine. Consequently, other diag-
noses must be kept in mind, even in areas endemic for
tuberculosis.
Computer-assisted tomography and magnetic reso-
nance imaging disclose morphological abnormalities re-
lated to vertebral and disc infection. Computer-assisted
tomography is of great value in the delineation of en-
croachment of the spinal canal by posterior extension
of inflammatory tissue, bone, or disc material6"; in the
guidance of biopsies; and in the planning of operative
procedures.
Magnetic resonance imaging is most useful for de-
lineating soft-tissue masses in both the sagittal and
the coronal plane and for indicating the extent of dis-
ease and the spread of tuberculous debris under the
anterior and posterior ligaments. The subligamentous
spread of a paraspinal mass and the involvement of
multiple contiguous bones strongly suggest infection,
but there is no pathognomonic finding on magnetic
resonance imaging that reliably differentiates tuber-
culosis from other spinal infections or from a possi-
294 H. G. WATTS AND R. M. LIFESO
ble neoplasm348. Magnetic resonance imaging may be
of greatest value in the evaluation of intramedullary
lesions and isolated extradural disease. Intramedul-
lary lesions include tuberculomas; spinal cord cavitation;
spinal cord edema; and possibly unsuspected, non-
contiguous lesions throughout the spine. Intraspinal le-
sions seem to be more common in tropical countries,
specifically India, and are relatively rare in the West32.
Magnetic resonance imaging also assists in the differen-
tiation of compression of the spinal cord by granulation
material from compression by hard material such as
bone or disc.
Despite newer modalities of imaging of the spine and
spinal cord, the cytological diagnosis of vertebral tuber-
culosis depends on the procurement of adequate tis-
sue for histological examination and culture. In settings
where the disease is rare or where there is a possibility
of multiple-drug-resistant organisms, computer-guided
fine-needle aspiration and biopsy should be the initial
invasive diagnostic procedure53. Aspiration of a para-
vertebral abscess is safe and very effective in rapidly
establishing the diagnosis. Sputum, urine, and tissue
from other involved sites should also be cultured73. In
one study, fine-needle aspiration biopsy was effective in
the diagnosis of nine of eleven patients who had a posi-
tive culture50. We have also found core needle biopsy
to be useful in the diagnosis of vertebral tuberculosis.
Treatment
Our recommendations for the management of pa-
tients who have acute spinal tuberculosis depend on
the availability of appropriate facilities and trained per-
sonnel. The absolute indications for operative interven-
tion are a marked neurological deficit, especially if it
is related to severe kyphosis or retropulsed bone or
disc in the neural canal; large abscesses in a patient
in whom respiratory obstruction has developed; a neu-
rological deficit that has worsened despite adequate
chemotherapy; and continuing progression of kyphosis
or instability despite adequate chemotherapy. Rela-
tive indications for operative intervention are related to
the inability to obtain adequate material for culture by
other means, neurological deficits in patients for whom
prolonged bed rest may lead to other problems, persis-
tence of pain or spasticity caused by a demonstrable
mechanical block, or pain related to spinal instability
where spontaneous fusion has not occurred34,51-78-85"87.
There is continuing debate regarding the necessity
of operative intervention in the spine to decrease the
occurrence of late kyphosis compared with the use of
chemotherapy alone. The Medical Research Council of
the United Kingdom, in multiple studies throughout
the world, has shown that drug therapy alone can be
effective treatment for tuberculosis of the spine, with an
acceptable resolution of neurological sequelae and pre-
vention of substantial progression of the kyphosis in
most patients25-52-54-78. The likelihood of progressive kypho-
sis developing depends on the site of the disease, the age
of the patient, and the number of vertebrae involved6264-90.
In areas of the spine where there is pre-existing ky-
phosis, such as the thoracic spine and the cervical-
thoracic junction, the likelihood of a late increase in
kyphosis is high. Conversely, in areas of the spine where
there is pre-existing lordosis, such as the lumbar spine,
late kyphosis is a less common and serious occurrence.
In children, tuberculosis of the spine generally in-
volves the osseous tissue of the vertebrae and not the
cartilaginous growth plate. After the disease has been
controlled with medication, the end plates can continue
to grow and, as a consequence, approximately 50 per
cent of children have a reduction in the kyphotic de-
formity with time. This is particularly true for children
who are less than five years old63-64. Similarly, if only one
or two vertebrae are involved, the probability of pro-
gressive kyphosis is low, but the likelihood increases if
more than two vertebrae are involved and varies with
the number of vertebrae involved64-83.
In the Medical Research Council study in Hong
Kong, proponents of operative intervention in tuber-
culous spondylitis showed that, at a mean of fifteen
years, radical debridement and arthrodesis produced
better results than radical debridement alone5178S6.There
was no increase in kyphosis in the patients who had had
debridement and arthrodesis, but there was a mean in-
crease of approximately 12 degrees in both the patients
who had had debridement alone and those who had
had non-operative treatment. Similarly, children who
had been followed for a mean of seventeen years in a
study by the Medical Research Council in Hong Kong
had a better end result after radical debridement and
arthrodesis than after debridement alone85-87. The chil-
dren who had had debridement and arthrodesis had an
over-all correction of kyphosis, whereas those who had
had debridement alone had an increase in the kyphosis.
Both procedures had similar results regarding recov-
ery from neurological deficits and relief of pain. Con-
sequently, if an operation is indicated, decompression
should be combined with arthrodesis.
Spinal tuberculosis primarily involves the anterior
vertebral structures and, therefore, anterior operative
approaches are usually recommended. From an anterior
approach, abscesses can be evacuated, all avascular ma-
terial can be excised, and anterior decompression of the
spinal cord can be performed safely. Tissue is easily
obtained for histological study and culture, and the ky-
phosis can be corrected or at least stabilized with use of
autogenous bone graft.
Indications for posterior operative approaches to
the spine, although rare, include situations in which the
posterior spinal elements are more involved than the
anterior ones or those in which both the anterior and
the posterior elements are involved and posterior stabi-
lization is needed before anterior decompression and
arthrodesis is performed82.
T H E J O U R N A L OF BONE A N D JOINT S U R G E R Y
 TUBERCULOSIS OF BONES AND JOINTS 295

At specific anatomical sites, such as the occipito-
cervical junction, we recommend a transoral biopsy to
decompress and obtain tissue for culture, followed by
a posterior stabilization procedure46. A posterior opera-
tive approach is also indicated in patients with a sta-
ble spine who have slight deformity or involvement
of the bone but who also have intramedullary or pos-
sibly extramedullary tuberculomas and an epidural
abscess.
The costotransversectomy approach has somewhat
limited applications but is useful for the drainage of a
large abscess in the thoracic spine in a patient who is
not medically fit to have a formal thoracotomy. It is also
useful in patients with substantial thoracic kyphosis, in
whom an anterior transthoracic approach is technically
difficult. Often, a costotransversectomy allows sufficient
exposure for removal of an anterior bone bar and for
limited bone-grafting.
Posterior stabilization with various metallic im-
plants does not appear to increase the risk of prolonged
infection, and it may allow patients to be mobilized
earlier with less need for postoperative immobiliza-
tion56. We do not have any personal experience with
attempted closed reduction of kyphotic deformities, al-
though the method appears to be simple and inexpen-
sive and does not require special expertise in terms of
anesthetic management. However, prolonged immobi-
lization of the spine is required after the manipulation26.
Late-onset paraplegia occurs in patients in whom
a marked kyphotic deformity has developed and who
have had prolonged anterior impingement on the cord
by a sharp osseous kyphosis or possibly from constric-
tion caused by fibrosis around the neural elements. Os-
seous and fibrous material anterior to the spinal cord
must be removed very carefully and, because of the
severe angulation of the osseous deformity, the opera-
tive procedure is technically difficult. Even with ade-
quate decompression, recovery of normal neurological
function is prolonged and usually incomplete. This is
probably because of vascular insufficiency in addition to
marked myelopathic changes in the cord34.
Some authors49 have recommended the use of ante-
rior vascularized bone grafts followed by posterior os-
teotomy and arthrodesis with the placement of internal
fixation devices to correct a fixed kyphosis. The concept
involves elongation of the anterior column with a simul-
taneous shortening of the posterior column. This proce-
dure is costly and requires longer hospitalization and a
great deal of operative expertise; however, it may pro-
duce a more cosmetically acceptable and better bal-
anced spine.
It has been reported that there is no substantial
progression of kyphosis after a short anterior arthrode-
sis of the spine in children, even if the procedure is
performed at an early age88. Specifically, there does not
appear to be posterior spinal overgrowth contributing
to a recurrence of the deformity. Consequently, prophy-
lactic posterior arthrodesis of the spine in a growing
child is not indicated after an adequate anterior decom-
pression and arthrodesis88.
It has been our experience that adequate anterior
decompression reliably leads to resolution of paraple-
gia if it is performed within nine months after the on-
set of acute paraplegia. Operative decompression can
lead to substantial neurological improvement if it is per-
formed between nine and eleven months after the onset
of paraplegia, although spasticity will probably remain
and the degree of resolution is usually incomplete.
Ho and Leong found that operative intervention more
than one year after the onset of paraplegia rarely erad-
icated neurological deficits completely, and an opera-
tion performed after two years rarely led to substantial
recovery of spinal cord function34.
Tuberculosis remains a major public-health problem
in most of the world. It is axiomatic that, before the
disease can be treated, it must be recognized and, before
it can be recognized, it must be considered a diagnostic
possibility.

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