Transcript Tuberculosis of Hip

Skeletal
Tuberculosis
(Part-2)
Dr. Sunil Arora
Junior Resident
Deptt. of Chest &TB
Govt. Medical College, Patiala.
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1
Introduction
Skeletal TB accounts for 10 to 35% of cases of
extrapulmonary tuberculosis. Although spine is the
commonest site (constituting about 50%) of skeletal
TB. The other bones and joints can also be involved.
Skeletal TB generally occurs due to haematogenous
spread from a primary focus.
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Classification
 TUBERCULAR ARTHRITIS- 30%
HIP JOINT
KNEE
WRIST JOINT
SACROILIAC JOINT
ANKLE JOINT AND FOOT
SHOULDER JOINT
 TUBERCULAR OSTEOMYELITIS- 19%
LONG TUBULAR BONES
SHORT TUBULAR BONES
FLAT BONES- RIBS,STERNUM, SCAPULA, PELVIS
 TENOSYNOVITIS/BURSITIS- 1%
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Pathogenesis
• It produces similar response as in lungs i.e.
Chronic
granulomatous inflammation.The
disease process can start either in bone or in the
synovial membrane.
• Active focus forms in the metaphysis (in
children) or epiphysis (in adults) and the
inflammation extends peripherally along the
shaft to reach the subperiosteal space.
• The inflammatory exudate may extend outward
through the soft tissue to form cold abscess and
sinuses.The affected bone may undergo
fracture.
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• Metaphyseal infection reaches the joint through
subperiosteal space by penetrating the capsular
attachment.In adults,the inflammation can
spread up to the subchondral area and enter the
joint at the periphery where synovium joins the
cartilage which leads to the loosening the
attachment of articular cartilage and joint
displacement.
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• Sometimes the synovium is infected first and the
bone is infected secondarily.It is usually in the form
of low-grade synovitis with thickening of the synovial
membrane and leading to the formation of
pannus.Eventually,the
articular
cartilage
is
destroyed,joint gets distended with pus,which may
burst out to form a cold abscess or discharging
sinus.The joint may also get subluxated due to the
laxity of the joint capsule and ligaments.
• Fibrous ankylosis is a common outcome of healed
tuberculosis of the joints except in spine where bony
ankylosis follows more often.
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Types
Two classical forms of disease have been seen;granular and and
exudative(caseous) that involve the bone and synovium.Both
the patterns have been observed in patients of skeletal TB,one
form may predominate.
1.Osseous granular type :-often follows trauma
-insidious onset,constitutional symptoms rare,
-soft tissue are slightly warm and tender
-healing without residual joint scarring&ankylosis
2. Osseous exudative(caseous) type:-rapid onset,constitutional symptoms,muscle pain and
spasm more marked
-soft tissue are warm,swollen and tender
-caseous material penetrates into jointdestructive arthritis
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-healing by joint scarring&ankylosis
Clinical Features
•
•
•
•
TB should be included in the differential diagnosis of any
slow onset of disease of musculo-skeletal system
particularly in TB prevalent countries like
India.Symptoms can be:Constitutional symptoms:–
The patient may be apathetic and pale
Loss of weight and appetite
Low grade fever(especially in the afternoons)
Night sweats,tachycardia
These constitutional symptoms may be present
before the definite symptoms pertaining to specific
bone/joint involved.
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Local clinical features— These are specific to the site
involved. But generally:Pain
Swelling (may be due to cold abscess)
Night cries (in children due to rubbing of the two surfaces
on movements during sleep after muscle relaxation)
Painful limitation of movements
Muscle wasting
Sinus formation
Deformities (in later stages)
Patient may give a fallacious history of trauma which
might have drawn the attention to a pre-existing lesion or
activated a latent tubercular focus.
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Investigation
Radiological Examination-
• Findings in early stages may be minimal and likely to be
missed.A comparison with identical x-ray of opposite limb
may be helpful.
• Localized osteoporosis is the first radiological sign of active
disease.The articular margins become indefinite with areas
of destruction,osteolysis and marked peri-articular
rarefaction along with reduction in joint space.
• The synovial fluid,synovium and capsule may cause a soft
tissue swelling.
• In advanced stages-subluxation,dislocation and deformity
of the joint.
• Chest X-ray-to detect any tubercular lesion in the lungs.
• MRI scan and Bone scan are useful in early diagnosis.
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Other investigations
• Haemogram – It may show anemia, lymphocytic
leucocytosis,high ESR
• Mx test – useful in children.
• Synovial fluid aspiration –
-ADA Levels(Non TB septic arthritis patients have been
reportedly higher than other types of inflammatory
arthritis but not as high as TB arthritis).
- Culture.
• Aspiration of cold abscess- Histopathological
examination,Smear for AFB & culture.
• Biopsy- in doubtful diagnosis,may be from
synovium,bone.
• FNAC from lymph node
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Treatment
• Aim of the treatment is to1. Control of the infection &
2. Care of the diseased part
In most cases conservative treatment is sufficient,but
sometimes operative interventions are required.
Conservative treatment ATT-As per RNTCP guidelines all Extra pulmonary new TB
cases are to be given Cat-1.Which includes:Intensive phase - 2 months which includes
Rifampicin(450mg),Isoniazid(600mg),Ethambutol(1200mg)
&Pyrazinamide(1500mg)
Continuation phase – 4 months of Isoniazid and
Rifampicin
i.e.regimen is 2H3R3Z3E3+4H3R3 & continuation phase
shall be extended by 3 months making the total duration of
treatment to a total of 9 months for osteo-articular TB.
 Anti-inflammatory,pain killer&antipyretics (as and when
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required)
 Drainage of cold abscess should be done
without delay to avoid sinus formation(by antigravity technique).
 Antibiotic for secondary infection(for persistently
draining sinus which gets secondary infections).
 Bed sore care and treat other comorbid
condition.
 Building up of patient’s resistance – High
protein diet.
 Excision of sinus tract - if sinus are persisting.
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 Rest and brace
• Affected part should be rested during active stage of the
disease.In upper limbs this can be done with the help of
plaster slab and in lower limbs traction can be applied. As the
disease comes under control and the pain reduces,joint
mobilization is begun.Gradual mobilization should be
encouraged with the help of suitable braces/appliances after
3-6 months of start of treatment when the healing is
progressing, which are gradually discarded after about 2
years.
• Exercise is started as the joint regains movement and weight
bearing started gradually as osteoporosis secondary to
disease is reversed
• In presence of gross destruction especially in weight bearing
joints, immobilization may be continued to obtain sound
ankylosis.
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Surgery in Skeletal TB
It is an adjunct to the anti-tubercular therapy,not a
substitute.Following surgical procedures are employed for
specific indications:1. Excision of osseous focus threatening the integrity of
neighbouring joint.
2.Excision of entire/part of bone with evidence of gross
destruction.
3.Synovectomy in synovial TB,not responding to
conservative treatment.
4. Osteotomy to correct deformity when the joint has healed
in a bad position
5. Arthrodesis to obtain a sound ankylosis in advanced
disease(knee,hip, ankle,wrist)
6. Salvage operations are the procedures to perform in
markedly destroyed joints in order to salvage whatever useful
functions are possible.( e.g.Girdlestone arthroplsty)
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Tuberculosis of Hip
It occurs in about 15% of all cases of osteoarticular TB. It
almost always start in bone and initial focus is in the :1. Acetabulum roof
2. Femoral epiphysis
3. Proximal femoral metaphysis
4. Greater trochanter
5. Synovial membrane(rare) & disease may remain as synovitis
for a few months.
Since the head and neck of femur are intracapsular, a bony
lesion here invades the joint early & later spread to involve the
acetabulum . When disease starts in the acetabulum ,
symptoms related to joint involvement appears late.Multiple
cavitations occurs in femoral head and acetabulum.
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Stages of TB of Hip
Classical untreated TB of hip passes through following 3 stages
Stage 1 (stage of synovitis) –Intrasynovial effusion and exudate
distending the joint capsule demanding the hip to be in a position of
maximum capacity i.e. position of flexion, abduction &external
rotation. As the pelvis tilts to compensate for abduction and flexion
deformities so the affected limb appears longer. This is a stage of
apparent lengthening.
Stage 2 (stage of Arthritis)- The capsule and articular cartilage is
involved leading to spasm of powerful muscle. The hip joint
assumes a position of flexion, adduction & internal rotation. The
flexion & adduction may be concealed by compensatory tilt, the
affected limb appears shorter i.e. stage of apparent shortening.
Stage 3 (stage of Erosion)-The capsule is further destroyed, along with
advanced destruction of cartilage and the head and/or acetabulum
is eroded. The attitude of limb is flexion , adduction and internal
rotation.There is true shortening of the limb because of the actual
destruction of bone.The destroyed head may come to lie proximally
and posteriorlyWandering acetabulum or instead protrusio
acetabuli can develop with destruction of medial wall of acetabulum17
EXAMINATION
It should be carried out with the patient undressed.
 Gait – Lameness is one of the first sign. In the early stage, it is
because of the stiffness and deformity of the hip. Because of the
flexion deformity, patient stands with compensatory exaggerated
lumbar lordosis.Later, the limp is exaggerated by pain, so that,the
patient hastens to take the weight of the affected side(painful or
antalgic gait).
 Muscle wasting of thigh and gluteal muscles.
 Swelling due to cold abscess-Sometimes joint space is filled
with caseous material and it may track down to the path of least
resistance resulting in cold abscesses in:1.Inguinal region 2.Femoral triangle 3.ischiorectal fossa
4.Adductor compartment of thigh 5. Greater trochanter
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 Discharging sinuses in the groin or around the
greater trochanter. There may be puckered scars from
healed sinuses.
 Deformity – Minimal deformities are compensated by
pelvic tilt. Commonly it is flexion, adduction & internal
rotation.
 Shortening – Generally true shortening except in
stage 1 ( which is apparent lengthening ).
 Movements –Limitations of active and passive
movements in all directions. If no movement at al
( Bony ankylosis )
 Abnormal positioning of head-In a dislocated
hip,head can be felt in gluteal region.
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Investigation
1.Radiological ExaminationX-rays AP &lateral view.
2.Other investigationsIncludes blood investigation,Mx,Synovial fluid
examination, biopsy.
MRI scan and Bone scan are useful in early
diagnosis
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Soft tissue swelling, osteoporosis, and loss of bone definition, as can be
seen by comparison with the normal left hip
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Radiological Types
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Seven different types of radiological appearances in advance stage of TB hip
joint are as:Normal type – Disease is mainly synovial, may be cysts in femoral neck,
head or acetabulum, but no gross destruction and joint space is normal.
Perthes type – Generally seen under 5 years of age,Femoral head is
sclerotic and it is difficult to differentiate from Perthes disease.
Dislocating type – Subluxation or dislocation of femoral head occurs due
to capsular laxity and synovial hypertrophy(not due to accumulation of pus).
Wandering acetabulum-There occurs destruction of acetabulum of its
superior (weight bearing part)&femoral head shifts proximally on the ilium.
Atrophic type – Femoral head is irregular and joint space is narrow.
Seen exclusively in adults.
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Protrusioacetabuli-medialization of the medial wall of the acetabulum.

Mortar and Pastle type – Destruction causes enlargement and deepening
of acetabulum and femoral head shifts medially..
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NORMAL
TYPE
Radiograph of a 3-year-old girl with the
normal’ type of tuberculosis of the right hip
showing osteopenia and acetabular cysts.
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PERTHES
TYPE
Left femoral epiphysis is flattened absence of metaphyseal changes and presence
of juxta-articular osteopenia favour TB over perthes disease.
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DISLOCATING
TYPE
Rt Femur head gets dislocated due to capsular laxity and synovial hypertrophy rather
than pus accumulation as in pyogenic arthiritis.
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WANDERING ACETABULUM-
The upper
part of femur displace upwards and dorsally leaving lower part of
acetabulum empty.
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ATROPHIC
TYPE
Radiograph demonstrates
complete joint destruction in
the right hip, along with
associated soft-tissue
swelling and calcification.
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MORTAR AND PESTLE TYPE : femoral head
and neck are grossly destroyed, collapsed and contained in a large
acetabulum
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Differential Diagnosis
TB of hip is the commonest cause of pain in the hip in
children in TB prevalent countries.The following
differential diagnosis should be considered:
a) Rheumatoid arthritis- In rheumatoid arthritis B/L
symmetrical, more small joint involvement,h/o
remissions &the joint space is uniformly reduced,
b) Inguinal LAN or Psoas Abscess – Patients with
these extra articular diseases often present with the
flexion deformity of hip because of spasm of iliopsoas.
All movements of the hip expect extension are pain
free.
c) Pyogenic arthritis- It can be differentiated as:-
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Variables
Radiological
progression
Marginal erosions
Joint
narrowing
Periostitis
space
Pyogenic
(non-tubercular)
Rapid,short history
Early
areas)
Early
(wt.bearing
Common
TB
Slow,
onset
insidious
Late
(non
bearing
Late
wt.
and
Sclerosis
Present
Rare (thin
parallel)
+/-
Osteoporosis
Minimal
Marked
Ankylosis
Bony (common)
Fibrous except in
spine where bony
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d) Congenital dislocation of hip – Limp is painless, generally
detected at birth. Telescopy test is positive and X-ray are
decisive.
e) Congenital coxavara – Painless limp, abduction and internal
rotation are limited.Adduction and external rotation maybe
increased. X-ray usually confirms the diagnosis.
f) Perthe’s Disease –Seen in age group of 5-10 years, associated
with minimal limitation of movements,mainly abduction and
internal rotation. Typical X-ray changes are out of proportions
to the physical findings. The joint space may be widened
(unlike TB). Absence of metaphyseal changes and presence of
juxta articular osteopenia favours TB
g) Osteoarthritis – occurs in older individuals.
- Hip movements are limited in all
directions but only terminally
.
- Associated pain and crepitus .
h) PVNS - lack of osteopenia,heavy hemosiderin deposits causes
prominent hypointensity on MRI
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Treatment
In early stagesConservative treatment-which includes
1.
ATT
2.
General care
3.
Care of hip- The affected hip is put to rest by immobilisation
using below knee skin traction.In stage (i & ii) traction upto 12
weeks maybe required. It should be continued till disease activity
is well controlled, hip movements improve and become pain free
and muscle spasm does not occur.
Gentle hip mobilisation and sitting in bed for short period are
started during the period of traction. For the next 12 weeks, non
weight bearing walking is allowed with crutches followed by
another 12 week period of partial weight bearing. Unprotected
weight bearing should not be permitted early to avoid collapse
and deformity.
• In stage 2- Partial synovectomy and curettage of osteolytic lesions
along with grafting.
• In stage 3- aim is to achieve fibrous ankylosis in a functional
position.
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Operative Management
•
•
•
•
In case of advanced disease where X-ray
picture suggests significant joint damage and
normal joint functions can not be regained.
Surgical options are:
Girdlestone arthroplastry- To provide a
painless, mobile but unstable joint.
Arthrodesis-To provide painless, stable but
fixed joint(patient unable to squat).
Corrective osteotomy
Total hip replacement
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Tuberculosis of Knee Joint
• It is the 3rd most common site for osteoarticular TB
accounting for about 10 % of cases of osteoatricular TB.
• Focus of infection may be from:1.Synovium(MC)
2.Subchondral cancellous bone.
3.Juxta-articular osseous focus in the epiphysis.
4.Physeal plate.
5.Metaphysis.
6.Patella(rare)
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Examination
 Pain and swelling in the knee- Gradual onset and later
increases and knee takes the attitude of flexion. There is
inflammatory exudates in the joint with supra patellar fullness
and filling of fossa on either side of patellar tendon.
 The synovium and capsule becomes palpably thickened and
tender”Doughy swelling”
 Movements-In synovial disease,may be terminally restricted
movements,but as arthritis sets in there is pain accompanied
by muscle spasm.
• Muscle atrophy of thigh muscles(quadriceps)
• Cold abscess either arround the knee or in the calf
• Sinus formation
• Deformity-In the early cases mild flexion deformity and later
triple deformity due to spasm and contracture of biceps
femoris and tensor fascia lata.It is:--Flexion of knee
--Posteriolateral subluxation of tibia&
--Lateral rotation and abduction of the leg
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Tuberculous arthritis of the
knee joint. Frontal radiograph
demonstrates
periarticular
osteopenia (black arrow),
peripheral osseous erosions
(white arrow), and relative
preservation of the joint
space.
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SOFT TISSUE TUBERCULOSIS ALONG THE MEDIAL ASPECT OF THE LEFT KNEE.
High-signal-intensity soft tissue abscess(white arrow), with adjacent bone
marrow edema involving the medial condyle and a T2 hyperintense focus in the
medial proximal tibia (black arrow) due to the associated osteomyelitis
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Differential diagnosis
• Meniscal tear and synovitis due to trauma-generally young
persons engaged in sports,h/o classic twisting injury of the knee,
recurrent episodes of pain and sudden locking and unlocking of
knee.
• Rheumatic arthritis(children)—in children,h/o sore throat,migratory
polyarthritis,cardiac involvement.
• Rheumatoid arthritis(adults)
• Subacute pyogenic infection
• Villonodular synovitis.
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Management
• Aim is to achieve a painless mobile joint.But it is possible
in early stages.In later stages,some amount of pain and
stiffness persists in spite of treatment.
• General care
• Local care-In early stages the treatment is usually
conservative with antitubercular drugs and
immobilization in a below knee skin traction or an aboveknee POP cast till the disease is quiescent after which
the patient can be mobilized.
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Operative Treatment
• Synovectomy: may be required in cases of purely
synovial TB,which is not responding to conservative
treatment or doubtfull treatment.
• Joint debridement: the pus is drained,synovium
excised and all cavities curetted.
• Arthrodesis: In advanced stage with triple
subluxation and cartilage destruction.One such
method is Charnley’s compression arthrodesis
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TB of Ankle and Foot
• Accounts for less than 5% of osteoarticular TB.
• Tarsals and the ankle joint are usually involved together
due to intercommunicating synovial channels.
• Most commonly starts as synovitis.Usually it presents as
synovial disease or extra-synovial soft tissue disease
associated with bony focus.
• MC affected bone is calcaneum followed by talus,1st
metatarsal,navicular and medial 2 cuneiform bones.
• Multiple lesions,abscess and sinus formation are
common in adults but synovial disease is more common
in children.
• Clinical and radiological features are same as of other
joints.
• Synovial biopsy may be needed for the confirmation of
diagnosis
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D Collapse and destruction of the os calcis with marked soft tissue
swelling and generalized osteoporosis. The infection is in the os
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calcis, but the whole joint will eventually be destroyed
Tuberculous arthritis of the ankle joint
Sagittal T1-weighted MRI demonstrates hypointense periarticular effusions
(black arrows) with bone erosion of the talus and tibia (white arrow).
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Management
• Antitubercular drugs along with pain killer(if
required)&genaral care.
• POP cast to give rest: in 10 degree equines position.
• An extensive,long standing disease requires arthrotomy
and synovectomy.
• An isolates bony lesion should be curetted and large
cavities should be packed with bone grafts.
• In extensive joint destruction,arthrodesis of ankle or
subtalar joint alone or together.
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TB of Shoulder Joint
• Rare,only 1-2% of all osteoarticular cases.
• Disease originates in head of humerous,
glenoid.Synovial variety is rare..
• Common variety is dry and atrophic type—Caries sicca..
• In children lesion may start in metaphyseal region of
humerus and affects longitudinal growth.
• Joint involvement is early with painful limitation of all
movements esp.abduction and external rotation.
• Swelling,abscess and sinus formation are rare.
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• In early stages,some swelling,thickening and tenderness in
soft tissue around the joint is present.
• Marked wasting of deltoid and supraspinatus musle may
occur along with axillary lymphadenopathy.
• D/D include frozen shoulder in early stage of TB shoulder
joint and Rheumatiod arthritis in late stage(Marked soft
tissue swelling and effusion occurs in Rh.arthritis)
• In doubtful cases synovial biopsy can be sent for
microbiological and histopathilogical examination.
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Caries sicca. There is erosion and destruction of humoral head and
glenoid cavity with soft tissue swelling, along with fibrotic opacities..
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Management
• Genarally shoulder joint TB responds well to
antituberculosis treatment.
• In addition to general treatment for TB,shoulder
joint is immobilized in Saluting position to
encourage ankylosis of gleno-humeral
articulation in functional position.
• If ankylosis is painful, disease is uncontrolled or
reccurance,arthodesis is carried out
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Tuberculosis of elbow joint
2% or less of all osteoarticular TB, adults are more affected.
Osseus focus is in the olecranon>coronoid> lower end of
humerus or upper
end of radius. Synovial disease is
uncommon.
Swelling is appreciated at the back of elbow on both sides of
olecranon & triceps tendon.
The principle underlying the management are similar to TB of
other synovial joints.
In all stages of disease,elbow should be immobilized in an
above elbow plaster cast in 90 degree flexion and mid prone
position and when the acute stage is under control, intermittent
active & assisted exercise is carried out.
 Surgical debridement with or without excision may be
required for advance disease and surgical excision of a juxta –
articular osseus lesion is indicated to prevent extension of
disease to joint.
 Arthrodesis of elbow is rarely required for heavy manual work
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Lateral view of elbow joint involved by TB showing lytic lesion in olecranon [arrow] and
loss of joint space with flexion deformity
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Tuberculosis of Wrist Joint
 Rare & mainly seen in adults.
 Most common site of initial focus are distal radius &
capitate and less often in synovium and Infection
spreads to involve intercarpal&wrist joint,flexor and
extensor tendon sheath. Abscess & sinus formation
are common.
 Onset in insidious, exacerbation of pain by
movements occur early &soft tissue swelling,
limitation of flexor & extensor movement occurs late.
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There is complete destruction of the radiocarpal,
midcarpal, and carpometacarpal articulations, as
well as sclerotic changes in the distal radius and
ulna.There is osteoporosis distal to the affected
joints and the soft-tissue swelling
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Management
 TB of wrist joint is quite likely to be misdiagnosed so It is
essential to confirm the diagnosis with synovial biopsy to
differentiate it from mono articular rheumatoid arthritis.
 On early diagnosis, patient should be treated with
antitubercular treatment & anti inflammatory drugs.
 Prolonged splintage with wrist in 10 degree dorsiflexion
and in mid prone position is always required.
 Heavy physical work is avoided for 18-24 months.
 Synovectomy & curettage of bony lesions are indicated
in non responding patients.
 In advanced destruction, arthodesis is the treatment of
choice.
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TB of Sacroiliac Joint
• It is a pure synovial joint,involves in around 2-5% of
osteoarticular TB.More common in adults.(M:F=2:5)
• Lesion may start in sacrum,ilium or in synovium.Infection
can also extend from ipsilateral hip joint or lumbosacral
area of spine.
• Association with TB spine,hip,viscera are frequent.
• Abscess formation is common and it may be present
dorsally or inside the pelvis.
• Sinus formation also occurs.
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• Insidious in onset or may follow trauma/pregnancy.
• Pain is the main symptom, which may be referred to
groin/sciatic nerve distribution.Which is worsened on
lying in supine or on affected side Sitting on buttock
on affected side is painful,whearas on opposite side
pain is relieved.
• Sudden jerks,coughing,sneezing,stress on involved
SI joint increases pain.
• Rectal examination is important to detect intrapelvic
abscess.
• CT and MRI are helpful in detecting early joint
erosion,cavitation and abscess.
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Management
• Difficult to diagnose as presentation is atypical.
• ATT and general care along with rest&
mobilization when the acute symptoms
subsides.
• Less responsive to ATT,so surgery is generally
required.
• Surgical options are debridement of
joint,freshening of joint margins and adequate
grafting to achieve arthrodesis.Post-operative
bed rest is required for 3 months followed by
gradual mobilization in L-S belt.
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Other Rare Involvements
1. Sternoclavicular
2. Acromioclavicular
3. Symphysis Pubis
4. Ilium,Ischium and Ischiopubic ramus
5. Sternum and Ribs
6. Scapula
7. Clavicle
8. TB Tenosynovitis& TB Bursitis
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TB Osteomyelitis
• TB rarely affect the shaft of long bones. It is usually a low
grade subacute osteomyelitis.Common presenting features
are pain,swelling,tenderness,regional LAN,abscess and
sinus formation.
• An imp.radiological feature is that the bone lysis is out of
proportion to the new bone formation(unlike pyogenic
osteomyelitis).
• Biopsy for histopathological and micribiological
investigation may help in diagnosis.
• Short bones like phalanges(Spina
ventosa),metacarpals,metatarsals are involved in children.
• Disease process starts in medullary cavity diphysis
sequestration.
• Patient presents with gradual and painless swelling of one
of the phalanges.
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SPINA VENTOSA
Oblique film of the right hand shows expansive
fusiform lesions of the first and fifth metacarpals
associated with soft-tissue swelling; there is no
evidence of a periosteal reaction
Radiograph of the left hand : shows
cystic expansion of the proximal phalanx
of the index finger, a finding that is called
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spina ventosa.
• FDG-PET{Flourine flouro deoxyglucose positron
emission tomography} has been found to be useful in
localizing TB disease in inaccessible or obscure sites.
• Response to Antituberculosis drugs is good.
• Refractory cases or in presence of abscess around the
bone may require excision of granulation tissue and
infected bone.
• Additional antibiotic for secondary infection through
sinuses.
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THANK YOU
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