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Bone tuberculosis affects people of any age and social status. Among its forms, tuberculosis of the joints is most common. For an accurate diagnosis, you need to take more than one test and undergo instrumental studies. Where is pathology most often localized and how to recognize it?

Definition

Damage to the joints with Koch's bacillus is a form that refers to bone tuberculosis. In most cases, the joints of the legs (knees and hips) are affected. But there are exceptions when mycobacteria are localized in the elbow joints. Divided by age group:

• children are more likely to suffer from hip joints;
• teenagers – knee;
• adults – elbows, ankles, shoulders.

Causes

The bacillus that affects the joints can enter the body in various ways, namely:

• contact – the skin and conjunctiva of the eyes are involved;
• airborne droplets - during talking, coughing and sneezing of an infected person;
• in utero - a sick mother transmits mycobacterium to the fetus.

In addition, the infection can enter the body with food. After this, tuberculosis begins in any organ, from where it travels through the bloodstream to the joints and bones.

Risk factors and groups

Risk factors include people who:

• have weak immune defense;
• eat poorly;
• live in poor living conditions (dampness, dirt, etc.);
• have harmful production;
• ever injured joints or bones;
• work hard;
• little rest.

Also at risk include the following persons:

• veterinarians;
• phthisiatricians and tuberculosis dispensary employees;
• butchers;
• pathologists;
• diabetics;
• HIV-infected.

Signs and symptoms

The first signs of such tuberculosis are:

• weakness;
• excessive irritability;
• decreased appetite;
• fast fatiguability;
• presence of low-grade fever.

At the second stage, there is a violation in the functionality of the area where the MBC was localized. An inflammatory process of the surrounding tissue appears. The leg/arm becomes weak and gets tired quickly. If the pathology affects the lower limb, lameness is visible and the gait changes.

If the upper one, then it becomes impossible to carry out the previous loads. The second stage is characterized by the rapid disappearance of these symptoms during rest. But, in any case, even after treatment, muscle tissue atrophy may remain.

The next stage is more serious atrophic phenomena, hypotension. There is thickening of the joint. Motor activity is limited.

Subsequently, effusion appears, abscesses, swelling increases, nerves and blood vessels are compressed. Pain occurs not only at the location of the pathology, but also in nearby areas.

Along with all of the above, it gets worse general health, available:

• temperature rise to 39 degrees;
• insomnia;
• complete refusal of food, etc.

To prevent irreversible processes from occurring, you should be examined promptly and begin treatment.

Forms

There are several forms, these are:

• Tuberculous tenosynovitis. This name refers to inflammation of the tendon sheath. The tuberculosis form is characterized by the formation of “rice bodies”. They are located in the extensions of the tendons. They are clearly audible to the touch.
• Tuberculous spondylitis. Pathology occurs in the area spinal column. In this case, the posture is deformed, a hump, paralysis and other equally unpleasant defects may appear.
• Tuberculous arthritis. The disease affects the spongy substance in the joint and its bursa. The result is painful sensations and the inability to move normally. The knees are most often affected.
• Tuberculous osteitis. The second name is tuberculous osteomyelitis. The vertebral bodies, femoral and tibial metaphyses, shoulder joints, ischial and pubic bones are affected.
• Tuberculous-allergic synovitis. There is inflammation in the synovium. In this case, there is an accumulation of effusion of the joint cavity. In most cases, the knee is affected.

Stages of tuberculosis

There are several stages of the disease:

1. Prearthric – primary. There are no obvious symptoms. There is only malaise and a slight rise in body temperature.
2. Arthritic – secondary. Three phases should be distinguished here: initial, peak and decay.
3. Post-aging – exacerbation of tuberculosis. There are relapses and complications.

Localization

Mycobacterium tuberculosis can grow and multiply anywhere. These can be joints of the knees, elbows, hips, ankles, shoulders, etc.

Shoulder joint

Tuberculosis of the shoulder joint (omartritis) occurs infrequently. If it is diagnosed, it is in adolescents and no later than 25 years of age. Initially, weakening of the arm and numbness occurs. If left untreated, the muscles will atrophy, fistulas may appear, and the infection will spread further (to the area of ​​the scapula). The arm shortens, bone tissue is destroyed, and a joint cavity occurs.

Knee joints

Tuberculosis of the knee joint (gonitis) appears in children of kindergarten age. You can suspect something wrong by the appearance of lameness, unsteadiness of gait, and the appearance of pain during physical activity. Shiny, smooth skin appears at the site of localization. If you press on the kneecap, it will squash. If an abscess occurs, pus may enter the joint (when the lesion ruptures). If this happens, the child’s leg does not bend, the lower leg and thigh become larger in volume. All this adds up to a significant increase in temperature.

Hip

Tuberculosis of the hip joint (coxitis) is characterized by severe inflammation of the connective tissues that line the tendons and joint cavity. Appears as:

• soreness;
• accumulation of fluid in the joint;
• the occurrence of a neoplasm, which then develops into an abscess or purulent inflammatory process (phlegmon).

Dislocations are possible later. The femur may become dislocated, the spinal column will become curved, and the pelvis will become irregularly shaped. At the same time, the temperature rises. If we talk about complications, this includes: immobilization of the joint, ankylosis, improper operation internal organs and systems.

Ankle

Tuberculosis of the ankle joint is a pathology that applies to the age group from 6 to 17 years. Gender doesn't matter. Initially, tuberculous pustules are detected. Over time, they burst, usually during exacerbations. In this case, the foot stops moving and swelling occurs. Fistulas appear at the back of the ankle. It is difficult to bend your leg. In extreme cases, it completely loses the ability to function in any way.

Radiocarpal

Tuberculosis of the wrist joint is characterized by swelling of the surrounding tissues. Afterwards comes pain and weakness of the arm. Muscle atrophy develops. There are also:

• fistulas;
• abscesses;
• fragility of bone tissue (fractures);
• blurred articular surfaces;
• areas with dead tissue.

Elbow

Tuberculosis of the elbow joint (fawnitis) tends to develop on right hand. It first appears as:

• rapid fatigue of the limb;
• changing its shape;
• joint swelling;
• inability to bend the elbow.

If left untreated, dislocation occurs. Then fistulas appear and the infection spreads. The lymph nodes in the axillary area are enlarged.

Diagnostics

TO diagnostic examination you need to take it seriously. The main thing is to identify tuberculosis at an early stage.

Helps diagnose the disease:

• x-ray - finds the primary focus;
• CT scan – shows in detail what is happening in the affected area;
• microbiological studies - shows whether there is a tuberculosis bacillus;
• samples - confirm the presence of Koch's bacillus (done first);
• fistulography - will be needed when fistulas have developed.

The above methods can be supplemented.

Treatment options

Treatment of joint tuberculosis is always complex. Be sure to pay attention to nutrition, taking medications, and rest. The joint should be at rest all the time. If the pathology has not reached its peak, but has just begun to develop, drug therapy is advisable.

Medication

To immobilize the affected area, a plaster splint is placed on it. The inflammatory process is eliminated with antibacterial treatment. It will also fight pathogens (mycobacteria).

The doctor prescribes anti-tuberculosis drugs. The most effective are Isoniazid, Streptomycin, Rifampicin. If they are not suitable for the patient. It makes sense to consider drugs that belong to the second line - Kanamycin, Ofloxacin. They are less effective, but there is no other choice.

You will also need to take immunomodulators.

Surgical

If the disease has reached a serious stage, when destruction has already begun, surgery is indicated. The affected joint is restored or replaced with a prosthesis. In any case, the lesion is removed, everything is treated with antiseptic drugs, and only after that the installation of the implant begins.

After any treatment, the rehabilitation period begins. At this time, the person must come to his senses and return to his normal life. Will help:

• physiotherapeutic procedures;
• massage therapy;
• Fresh air;
• positive emotions.

Forecast

Usually the prognosis for recovery is satisfactory. If the disease begins to deform the joints and modify them, people become disabled. Deaths are rare.

Complications

Tuberculosis of the joints is a disease that can disfigure the human body. The following may appear:

• joint deformation;
• influx and abscess, both in the area of ​​the lesion and away from it;
• poor posture;
• change in gait, lameness;
• hump;
• partial or complete immobilization of the joint;
• osteochondrosis;
• fistula, etc.

Only timely treatment and properly selected therapy will protect against unwanted consequences.

Conclusion

Tuberculosis of the joints occurs mainly before the age of 17 years. The initial symptoms do not portend a terrible disaster, but over time the condition worsens, and true signs of pathology appear. Only full examination will be able to clearly diagnose the disease. Timely treatment will protect you from disability and death.

13.03.2017

Involvement of the knee joint in tuberculosis is common, accounting for about 20% of all cases of osteoarticular tuberculosis.

General clinical symptoms in the prearthritic phase are associated with intoxication. Local manifestations are either completely absent, or are vague and poorly expressed, but the patient noticeably spares the affected limb.

The prearthritic phase can last a long time, especially in childhood, due to the fact that the epiphyses are covered with thick articular cartilage.

Primary lesions are more often found in the proximal epiphysis of the tibia (50%) and in the distal epiphysis of the femur (21.7%), less often in the metaphyses of these bones (10% and 2.3% of cases, respectively), and very rarely in the patella and epiphysis of the fibula (2.2%). The first radiological symptom of the tuberculous process is a limited area of ​​osteoporosis with an unclear pattern of bone trabeculae. Then a poorly defined focus of bone tissue destruction appears, which may contain small spongy sequestra.

Foci of destruction can be large, often in the shape of an hourglass, which is typical for damage to the knee joint. With the most common epimetaphyseal localization, foci of bone tissue destruction are usually located subcortically. Periostitis is not typical.

The arthritic phase of tuberculous gonitis is characterized by constancy clinical manifestations. Slight muscle atrophy, Alexandrov's symptom, swelling and pain in the joint, contractures, and increased local temperature appear.

Moreover, these symptoms persist even at rest. Some children experience lengthening of the affected limb. The joint is increased in volume, muscle atrophy gradually increases, subluxations of the lower leg, often posteriorly. Drip abscesses and fistulas appear.

X-ray manifestations of tuberculous gonitis are quite varied. However, the earliest symptom of the transition of the tuberculosis process to the joint is increasing diffuse or spotty osteoporosis, which gradually spreads to the bones of the entire limb. Moreover, the more acute the tuberculosis process, the more pronounced osteoporosis.

In children, there is an increase in the size of the epiphyses compared to a healthy limb; at the same time, the ossification nucleus of the patella may increase (a symptom of “aging of the epiphyses” by S. L. Tregubov).

The narrowing of the joint space gradually increases, which can sometimes be uneven, more pronounced on one side. However, this sign can sometimes be apparent and is associated with a slight flexion contracture. In such cases, it is necessary to take x-rays of a healthy knee joint in the same position for comparison.

Simultaneously with the narrowing of the joint space, unevenness and waviness of the articular surfaces appear, then blurred, jagged, and discontinuous contours of the articular surfaces appear. Regional foci of bone tissue destruction are identified, which can be located in opposite parts of the articulating bones and contain sequesters, often multiple.

The sequestra appear denser, “sclerosed” against the background of severe osteoporosis, their structure is spongy, “spongy”, and their contours are uneven. Signs of true bone atrophy gradually appear.

When the process subsides, no progression of destruction is observed radiographically. The contours of the foci of destruction first become clear, and then a delicate rim of sclerosis appears around them. The contours of the joint space, which has a bizarre shape, are revealed.

At the level of foci of destruction, it is unevenly expanded, and in those sections where the endplates of the epiphyses are preserved, it is sharply narrowed. Against the background of osteoporosis, thick, sclerotic bone beams appear located along the lines of force.

The endplates of the epiphyseal ends of the articulating bones are gradually restored and thickened.

The joint space narrows, sometimes it is not visible at all. Bone ankylosis is not often observed; fibrous adhesions, malposition and subluxations are more typical. In children, the longitudinal growth of bones is disrupted and their shortening is noted.

In less favorable cases, exacerbations and relapses are observed, which is associated with the presence of residual tuberculosis foci.

In these cases, intoxication and local changes increase. X-ray examination reveals an increase in osteoporosis, foci of destruction with unclear, uneven contours, sometimes containing sequesters, appear.

The endplates also become less clear. Destructive changes can be significant and lead to further destruction of the bones that form the joint.

Differential diagnosis of tuberculous gonitis must be carried out with a number of diseases: partial aseptic necrosis (Konig's disease), lytic variant of osteoblastoclastoma, osteogenic osteoclastic sarcoma, hemophilic arthrosis and rheumatoid arthritis.

Koenig's disease occurs in adults. Patients are bothered by pain in the knee joint, which intensifies with exercise.

There are no symptoms of intoxication. Stages I-II of Koenig's disease have to be differentiated from the tuberculosis process.

However, the absence of osteoporosis, the typical localization of the marginal focus of destruction in the medial femoral condyle, its small size, relatively clear contours, the presence of a dense sequester-like body with clear contours, the usual dimensions of the joint space - all this allows one to speak in favor of partial aseptic necrosis.

In differential diagnosis with osteogenic osteoclastic sarcoma, which is especially in initial stages proceeds without constant pain, a number of difficulties may arise. However, in children, osteogenic sarcoma is localized in the metaphysis. The focus of destruction is single with uneven, unclear contours, does not contain sequestration, osteoporosis in the adjacent parts of the bone tissue is not typical. A periosteal reaction of a mixed type is typical. Previously, there was a point of view that in sarcoma the process does not pass through the germinal zone. In recent years, the possibility of transition of the process of osteogenic sarcoma through the growth zone in children has been proven. However, destruction of articular cartilage and narrowing of the joint space is not observed.

In the lytic variant of osteoblastoclastoma, the focus of bone tissue destruction, localized in the epimetaphysis in adults and metadiaphysis in children, is often located eccentrically, causing an asymmetric club-shaped swelling of the bone in the early stages.

The focus of destruction has clear contours. Sclerotic demarcation and the presence of sequestra are not typical. Osteoporosis in the adjacent sections is not detected.

When conducting differential diagnosis with hemophilic arthrosis, it is necessary to take into account clinical, anamnestic and laboratory data. In patients with hemarthrosis, there are no symptoms of intoxication, there is a history of bleeding, and blood clotting is slowed down. In addition, hemophilia typically affects multiple joints.

X-ray examination may reveal osteoporosis, which affects the epiphyses and is not as widespread as with tuberculosis. There may be an increase in the size of the epiphyses compared to the healthy side. The contours of the endplates are uneven, but always clear, there are no sequesters.

In some cases, it may be necessary to conduct a differential diagnosis with rheumatoid arthritis, which in childhood can sometimes begin with damage to one joint. In these cases, it is necessary to take into account the duration of the disease, clinical and laboratory data. Rheumatoid arthritis is characterized by stiffness of movement in the morning, absence of symptoms of intoxication, and negative Alexandrov's sign. Tuberculin tests, as a rule, negative. A positive rheumatoid factor in the synovial fluid has diagnostic value.

X-ray examination of patients with rheumatoid arthritis reveals osteoporosis of the bones forming the knee joint, narrowing of the joint space. At the attachment points of the joint capsule, marginal lesions with clear contours and a rim of sclerosis around are detected.

With tuberculous gonitis, in the epimetaphysis of the tibia and femur, foci of destruction are revealed with unclear, corroded contours, gradually turning into osteoporotic bone tissue. Foci of destruction may contain spongy sequestra.

Tags: knee joint, drives, soft tissues, tibia, muscle atrophy
Start of activity (date): 03/13/2017 08:31:00
Created by (ID): 645
Key words: knee joint, knee joint, soft tissue, tibia, muscle atrophy

Tuberculosis of bones and joints affects 3-5% of people with the pulmonary form of the disease. In children and adolescents, the musculoskeletal system suffers much more often, and the disease itself has a more severe course.

Spinal tuberculosis.

Tuberculosis can affect almost any part of the skeleton. In half of the patients, the spine is always involved in the pathological process. This is due to its location in close proximity to the lungs. As for the hip, knee and other large joints, with tuberculosis they suffer slightly less often than the vertebrae. Even less commonly, the zygomatic bones, upper and lower jaw, hands and feet are affected.

Causes and mechanism of development of pathology

Tuberculosis of joints and bones is an infectious disease. It develops due to the hematogenous spread of mycobacteria throughout the body. Pathogenic microorganisms can be carried through the bloodstream to almost any part of the body. Having penetrated into the spongy substance of the bones, they cause the development of a specific inflammatory process there.

Specific inflammation has a severe course and characteristic distinctive signs. It develops in people infected with a specific pathogen. Specific inflammation can be caused by mycobacteria leprosy and tuberculosis, treponema pallidum and some other microorganisms.

In adults, bone tuberculosis usually develops against the background of pulmonary tuberculosis. Koch bacilli enter the systemic bloodstream from the lungs, and from there into the bone tissue. The musculoskeletal system is not affected immediately, but only with a long course of the disease. Alarming symptoms appear quite early, which makes it easy to suspect and diagnose pathology.

In childhood, the disease is most often a complication of vaccination. The vaccine strain of mycobacteria spreads throughout the body in the blood, causing the development of post-vaccination BCG osteitis. The disease has scanty symptoms and is characterized by massive bone destruction against the background of the child’s good general condition.

Stages of development of osteoarticular tuberculosis:

1. Primary osteitis.
2. Tuberculous arthritis.
3. Formation of ankylosis.

At first, only the spongy bones are involved in the pathological process. Tuberculous granulomas and encapsulated sequestra are formed in it. Subsequently, the person develops tuberculous arthritis. Articular cartilage is destroyed, and serous-fibrinous effusion accumulates in the synovial cavities. In case of rupture of the joint capsule, external fistulas are formed. As a result, the joint cavity is obliterated, which leads to a complete loss of its functions.

In regional and lymph nodes with osteoarticular tuberculosis, specific changes can also be detected. IN vascular walls, myocardium and joints in some patients, paraspecific reactions are detected.

In children, spondylitis is most often diagnosed at the age of 2-4 years, spondylitis is diagnosed at 4-7 years, the lesion upper limbs- at 15-18 years old.

Symptoms of tuberculosis of bones and joints

The disease is characterized by symptoms of general intoxication and local signs of skeletal damage. The first include sleep disorders, loss of appetite, periodic fluctuations in body temperature and autonomic disorders. Intoxication phenomena are more pronounced in children and are often absent in adults.

Heel pain may be the first symptom of tuberculosis of the bones and joints. This is explained by the early development of the pathological process in the heel bone due to the high load on it during walking.

Signs of spinal tuberculosis

At first, a person is worried about constant fatigue, general weakness and nightly back pain. Over time, the painful sensations intensify and begin to radiate to other parts of the body. In case of defeat cervical region In the spine, the pain spreads to the neck and suprascapular region, in the chest – the abdomen and chest, in the lumbosacral – lower extremities.

The pathology is characterized by the following symptoms:

• back muscle tension;
• forced incorrect posture;
• rachiocampsis;
• sharp pain in the back during exercise;
• gait disturbance;
• pain on palpation of the spinous processes of the vertebrae.

In the later stages, spinal tuberculosis may be accompanied by the formation of “cold abscesses.” Most often they are located on the back of the head, neck, hips, buttocks, and iliac region. Such abscesses do not cause symptoms of acute inflammation (pain, fever, local fever and redness of the skin).

Spinal tuberculosis often leads to severe complications. These include bedsores, dysfunction of the pelvic organs, paresis and paralysis of the muscles of the lower extremities.

Symptoms of tuberculosis of the knee joint

The first sign of pathology is constant pain in the knee, which intensifies when walking, bending and straightening the leg, and feeling the joint. Periarticular tissues become swollen and thickened. Over time, symptoms become more severe.

As the disease progresses, a person's muscles atrophy and flexion contracture of the limb develops. Because of this, it becomes extremely difficult for him to straighten his leg at the knee. In later stages, fistulas and abscesses can form in the periarticular tissues. With secondary infection of the joint, the patient may develop acute arthritis.

Symptoms of tuberculosis of the hip joint

It manifests itself as pain in the hip joint, which intensifies over time. Soon it becomes difficult for the patient to walk and perform usual activities. With tuberculosis of the hip joint, swelling of the periarticular tissues increases slowly, without fever and acute pain. Mild swelling can only be detected upon careful examination or palpation.

A typical symptom of joint tuberculosis is a local increase in skin temperature without hyperemia (redness).

Signs of damage to the maxillofacial area

The bones of the skull and face are affected extremely rarely - only in 1-2% of cases. Tuberculous granulomas are localized subperiosteally. The pathology is characterized by the presence of small round formations, painless or slightly painful on palpation. The skin over them usually remains unchanged.

Subsequently, abscesses form in the bones, which manifest themselves as swelling and fluctuation. Over time, they open with the formation of external fistulas. If the bones of the skull are affected, abscesses can break into the cranial cavity. Luckily it's solid meninges acts as a reliable barrier to the spread of tuberculosis.

Methods for diagnosing tuberculosis of bones and joints

In people with pulmonary tuberculosis, doctors can easily identify the disease. They use x-rays, CT scans, or MRIs to confirm the diagnosis. The detection of mycobacteria in a biopsy specimen or purulent discharge from fistulas is also of no small diagnostic importance.

In people who are not registered with a tuberculosis clinic, doctors cannot always suspect tuberculosis of the joints. They confuse the disease with chronic arthritis or osteoarthritis. Therefore, doctors should pay special attention to people at risk for tuberculosis who complain of constant pain in the back and limbs.

Osteoarticular tuberculosis can be confused with syphilis, actinomycosis, osteomyelitis, chronic arthritis, malignant neoplasm or other diseases. Doctors can make a correct diagnosis only after examination.

General principles of treatment

First of all, the patient is prescribed special anti-tuberculosis drugs. They are selected strictly individually. In some people, doctors can identify resistant forms of TB that do not respond to most modern drugs. It is especially difficult to fight them.

In the presence of large sequesters, abscesses and fistula tracts, patients are recommended to undergo surgical intervention. Surgeons excise pathological formations and wash the wounds with antibiotic solutions. In the later period, if necessary, the patient undergoes reconstructive surgery.

If you discover symptoms of joint tuberculosis in yourself or your child, contact a tuberculosis clinic for help. There they will examine you, register you and provide assistance.

Osteoarticular tuberculosis is a specific inflammatory disease, which develops during hematogenous dissemination of Mycobacterium tuberculosis from internal organs, primarily lung tissue.

The pathological process affects bones with well-developed spongy substance and rich microcirculation: vertebral bodies, epiphyses and diaphyses of long spongy bones. The shoulder, thigh, forearm, lower leg, all parts of the spinal column and associated joints are most often involved in inflammation during tuberculosis bone infection.

The disease occurs in both adults and children, while in childhood the pathology develops rapidly and causes severe anatomical and physiological complications due to the peculiarities of the bone structure and the active period of growth of the body. Tuberculosis of bones and joints, if not diagnosed and treated in a timely manner, leads to the formation of a hump, curvature of bones, complete immobility of the affected joints, muscle atrophy, and impaired motor activity in the form of paralysis and paresis.

Phases of disease development

In most cases, the disease appears as a result of active pulmonary tuberculosis, in which generalization occurs infectious process through the blood and lymphatic pathways. Among non-pulmonary tuberculosis, the most common lesions are the spine (40%), hip (25%) and knee joint (20%). The following risk factors contribute to the dissemination of pathogenic agents of specific inflammation:

• infectious diseases with a long course and frequent exacerbations;
• malnutrition, starvation;
• unsatisfactory social and living conditions;
• immunodeficiencies, including HIV/AIDS;
• chronic stress loads;
• hypothermia, physical overexertion;
• treatment with immunosuppressants, glucocorticoids, chemotherapy.

Appearance of a patient with spinal tuberculosis – formation of kyphosis (hump)

A specific process is formed in the myeloid substance of the red bone marrow, where tuberculous granulomas appear - epithelioid tubercles that are prone to fusion, the formation of conglomerates, and disintegration with characteristic cheesy necrosis. Depending on the prevalence of the pathological process, several phases of the disease are distinguished. The pre-arthritic, arthritic, post-arthritic phase is called in case of damage to the joints of long bones and the prespondylitic, spondylytic, post-spondylytic phase - in case of pathology of the spine.

Prearthritic, prespondylytic phase

It is characterized by the appearance of specific tuberculous osteitis; the infection is localized within the bone tissue and does not spread to the surrounding anatomical structures. The inflammatory process is located deep in the tubular bone, epiphysis or diaphysis, and is prone to a long, asymptomatic course, resulting in difficulties in determining the primary focus of infection dissemination. Bone trabeculae are gradually destroyed, bone tissue is discharged, and osteoporosis occurs.

Arthritic, spondylytic phase

Characterized by the emergence and progressive development of specific arthritis and spondylitis. In this case, the tuberculous lesion reaches the cortical (outer) layer of the bones or penetrates into the joint cavity through the synovial bursa. As a result, perifocal inflammation of the soft tissues develops with the formation of fistulas or synovial membranes (synovitis) with the appearance of a specific effusion into the joint cavity.

When the spine is damaged, tuberculous inflammation can spread to surrounding tissues through intradiscal and extradiscal pathways. In the first case, the pathological process destroys the intervertebral disc, and dystrophic disorders of the cartilage tissue lead to impaired mobility of the spinal column. In the second case, inflammation reaches the cortical layer of the vertebrae, destroys it, and affects the soft surrounding tissues with the formation of septic abscesses. When the infection spreads to the posterior parts of the spinal column, the spinal cord is affected.

Postartritic, post-spondylytic phase

It is characterized by a stable or temporary cessation of the inflammatory tuberculosis process with the preservation or progression of anatomical and physiological disorders formed during the active stage of the disease. Kyphosis, scoliosis, joint deformities, destruction and curvature of bones of varying severity are fully revealed in this phase of tuberculosis.

Clinical manifestations of the disease

The clinical picture of osteoarticular tuberculosis depends on the phase of development of the disease, the nature of the pathological process and the localization of specific inflammation, and the age group of the patient.

In adults, the disease at the initial stage occurs without obvious clinical manifestations; the period from the hematogenous introduction of mycobacteria to the appearance of the first symptoms can last several years.

Therefore, it is difficult to determine the primary source of infection, which may have healed by then. This is due to the strong structure of the bone beams and the dense cortical layer of bones over the age of 20 years. Strong immunity and good social conditions often lead to spontaneous resorption of tuberculous tubercles in the prearthritic (prespondylytic) phase of the disease.

On the contrary, in childhood the pathological process proceeds quickly and manifests itself with a clear clinical picture. Imperfect immunity in a child, even in satisfactory living conditions and with adequate nutrition, contributes to the development and progression of the disease. In patients of younger and middle childhood (up to 12 years), the bone beams and cortical layer of bones have a thin, fragile structure, and Bone marrow rich in vascular network. These anatomical features cause the introduction of mycobacteria from the primary focus (lungs), rapid melting of bone tissue, destruction of the cortical layer, and deformation of the joints.

X-ray of the spine - arrows indicate the area of ​​destruction of the vertebral body (sequestration)

Tuberculous spondylitis

Spondylitis of a tuberculous nature is quite common and ranks second after pulmonary tuberculosis. In the prespondylytic phase, adult patients are concerned about weakness, decreased performance, periodic increases in body temperature to subfebrile levels (37-37.5 degrees), and pain in the spinal column of undetermined localization. The pain syndrome intensifies as a result of prolonged physical activity and decreases after rest, especially night sleep. The child becomes less mobile, lethargic, capricious, appetite and interest in the world around him worsens. Tuberculous spondylitis is rarely diagnosed in the first phase due to the paucity of the clinical picture and negative results of x-ray examination.

More striking symptoms appear in the spondylytic phase, which in the initial period is characterized by the spread of infection beyond the bone lesion and increased intoxication. At the same time, pain syndrome increases, which may resemble costal neuralgia, sciatica, radiculitis and requires differential diagnosis with these diseases of a nonspecific nature.

Damage to the cervical spine causes pain in the back of the head, arms and fingers, thoracic– coughing, discomfort in the abdomen and lower back, lumbosacral region – pain along the sciatic nerve.

The back muscles become rigid, tension in the muscular frame impairs the mobility of the spine, posture and gait change, and fever appears. In case of defeat spinal cord paresis, paralysis, dysfunction of the pelvic organs (urinary and fecal incontinence) are formed.

X-ray of the destroyed right hip joint (left) due to tuberculosis

At the height of the disease, intoxication syndrome increases - body temperature reaches febrile levels (38-39 degrees), appetite worsens, body weight decreases, and sweating is characteristic. Increased pain is associated with the transition of tuberculous inflammation to adjacent vertebrae and destruction intervertebral discs. Movement in the affected parts of the spinal column becomes impossible, the back muscles atrophy, and deformation of the spine and chest appears. In the area of ​​the pathological process, fistulous tracts are formed with the release of whitish pus and particles of destroyed bone (sequestra) against the background of redness of the surrounding tissues. Drip abscesses are detected in the retropharyngeal space, in the mediastinum and lumbar region, on the thigh and perineum.

In the post-spondylytic phase, intoxication symptoms decrease, pain subsides, fistulas close, and edema abscesses resolve or calcify. Anatomical deformations of the spine come to the fore, which manifest themselves in the form of scoliosis, kyphosis, changes in the shape of the chest, spondylosis and spondyloarthrosis, deterioration in the functioning of internal organs, and atrophy of the muscular frame of the back. Relapses of a specific process occur frequently and are difficult.

Tuberculous coxarthrosis

Tuberculosis of the hip joint is accompanied by damage mainly to the acetabulum and head of the femur. In this case, a specific infection initially enters the diaphyses or metaphyses of the femur, and then granulation tissue melts the joint capsule, destroys cartilage tissue and articular surfaces of the bone. Due to disruption of anatomical structures hip joint becomes deformed and loses functional activity.

In the initial phase of the disease, general malaise, loss of appetite, and weakness appear. Dull pain periodically occurs in the affected leg It's a dull pain after physical activity, long walking, lameness appears at the end of the day. Rest and sleep at night calm the pain syndrome, so patients at this stage of the disease rarely see a doctor. In the arthritic phase, the symptoms of intoxication increase - the temperature rises, chills and sweating appear. The pain in the lower limb becomes unbearable, which leads to a sharp limitation of mobility. The diseased leg is in a bent state, brought to the hip of the healthy lower limb, and lumbar lordosis develops.

Atrophy of the thigh muscles and thickening of the skin folds in the area of ​​the pathological process (Alexandrov syndrome) gradually develop. Specific inflammation of the synovial membrane leads to the accumulation of effusion in the hip joint, an increase in its volume, and redness of the skin over the site of pathology. Drip abscesses often form in the perineum, lower back, anterior and inner thighs, followed by the formation of fistulas. In the post-arthritis phase, joint deformation and impaired motor activity of the limb are detected, the general condition improves, and the pain syndrome decreases.

Tuberculous gonarthrosis

Tuberculosis of the knee joint is less common than specific lesions of the hip. The pathological process is characterized by the same stages that develop with spondylitis and coxarthrosis. At the beginning of the disease, patients are bothered by periodic pain in the knee when walking, which stops after a short rest. The progression of tuberculosis causes damage to the synovial bursa and joint cavity, as a result of which its motor activity is sharply impaired, intoxication increases, and pain increases.

The picture shows tuberculosis of the knee joint

The accumulation of inflammatory exudate causes swelling at the site of the lesion, redness of the skin and an increase in local temperature. Contracture of the knee leads to atrophy of the lower leg muscles; in childhood, the growth nuclei in the epiphyses ossify prematurely, which causes shortening of the limb. The formation of leaky abscesses on the lower leg and foot leads to the appearance of fistulas, trophic disorders, and the addition of a secondary infection. During the period of subsidence of the disease, deformation of the bones of the lower leg and knee joint impairs its full mobility.

Therapy of osteoarticular tuberculosis

Treatment of tuberculosis of bones and joints is carried out surgically against the background of specific complex antibacterial therapy before and after surgery (ftivazide, streptomycin, PAS). The affected limb or spine is subject to immobilization during the active phase of the pathological process. For this purpose, a plaster cast, a crib, and splints are used, subject to hospitalization in specialized tuberculosis hospitals and sanatoriums. There are several types of surgical intervention:

For osteoarticular tuberculosis, it is often carried out surgery to preserve the function of joints and spine

• radical operations - complete removal of destroyed tissues of bones and joints;
• restorative operations – restoration of the normal function of the affected structures of the musculoskeletal system through plastic replacement with similar tissue or implants of artificial origin;
• reconstructive operations – endoprosthetics of bones and joints with significant destruction and severe anatomical defects.

Equally important is a nutritious diet with a high content of protein (up to 120 grams/day), calcium, and vitamins. Lean animal meat, poultry, dairy products, fruits and vegetables should be included in the daily diet. Long walks are recommended fresh air, sunbathing, gradual increase in physical activity. During the rehabilitation period, physiotherapy and a complex of physical therapy are prescribed.

Joint tuberculosis with early diagnosis and complex therapy has a favorable prognosis. Particular attention should be paid to children and adults suffering from the pulmonary form of the disease, as well as to persons in contact with tuberculosis patients, low social standards of living, and those with immunodeficiencies. When the disease develops, treatment must begin in the early stages of the pathological process, which will significantly reduce the anatomical deformation of the musculoskeletal system and help maintain full health. motor function joints.

In the knee joint, dropsy occurs more often than in all other joints, but it is not observed very often here either. Effusion in the joint cavity is determined radiographically by the pushing of the patella forward and by some convexity of the patellar ligament (lig. patellae proprium). In addition, the fluid itself gives a slight diffuse darkening in the superior inversion, which an experienced eye will detect instead of a more transparent area under normal conditions between the superoposterior surface of the patella and the femoral condylar mass. Behind and under the patella, fluid compression of the fat pad is visible behind and downwards. If there is no destruction of the ligamentous apparatus, then the x-ray joint space itself never expands, contrary to such a frequent erroneous conclusion, when a projection increase in the space is taken for true expansion under the psychological pressure of clinical data.

Common object of X-ray examination- these are fungous and fungous-destructive processes, especially in childhood and adolescence. In the primary bone process, the bone focus is most often located in one of the femoral condyles; much less often, the focus of destruction is nested in the posterior and lateral parts of one of the tibial condyles. Only in extremely rare cases does the primary bone process originate from the patella. Granulation tissue develops especially luxuriantly around the lower and lateral edges of the condyles of the femur and tibia, at the sites of attachment of the articular capsule to the bones, and from here granulations spread throughout the entire articular cavity, crawling mainly into pockets and inversions. Most of all, the posterior attachment points of the cruciate ligaments in the intercondylar fossae, as well as the attachment points of the semilunar cartilages (menisci), are destroyed. It is in these areas that edge defects first appear on radiographs. The anterior sections of the capsule suffer relatively little at the onset of tuberculous gonitis. In old, unfavorable cases of tuberculous gonitis, a lateral radiograph is characterized by a vicious position of the bones, expressed in subluxation or complete dislocation of the tibia backwards and upwards, so that the patella hangs forward and downward.

Although in the majority of cases, X-ray examination in the early stages of the disease provides only general symptoms protracted articular process, i.e. primarily osteoporosis, it must be done. There can be a very large discrepancy between the clinical and radiological pictures, and it is not too rare that decisive radiological symptoms, such as a bone lesion, appear unexpectedly precisely in those cases where this is least clinically suspected. On the other hand, a fairly substantiated clinical diagnosis of gonitis tuberculosa does not lose its credibility if radiographs reveal a normal picture or slight osteoporosis.

Let us remind you basic requirement- with a normal x-ray picture of the knee joint and the presence of clinical data in favor of osteoarticular tuberculosis, carry out mandatory x-ray monitoring of the condition of the hip joint: with damage to the hip joint, as is known, pain can radiate along the obturator nerve with its subpatellar branches (rami infrapatellares nervi obturatorii) in the area of ​​the knee joint.

With significant osteoporosis, the shadow of the patella may completely disappear without the bone being destroyed by granulation. An inexperienced researcher may mistakenly mistake Ludlof's spot for a bony focus of destruction (see Fig. 5).

A common mistake is also made when normal denticles on the medial contour of the epiphyseal ossification nucleus of the femur (Fig. 156) are interpreted as subchondral osteitis - a control photograph of the other limb dispels doubts. This roughness of the contours is a manifestation of a temporary acceleration of local growth and development that occurs at a certain age phase in every healthy child, and this normal process is not accompanied by any clinical painful symptoms. This, by the way, is a general phenomenon: in other places of the skeleton there are such diagnostically “critical” areas that attract special attention. These are, for example, the lateral side of the proximal epiphysis of the tibia, where the roughness of the contours is, however, less pronounced, as well as the epiphyses of the ulna, calcaneus, navicular bone of the foot, etc. Light areas in the epiphyses with spotted atrophy.

Rice. 156. Normal serration of the medial contour of the distal ossification nucleus of the femur, simulating tuberculous lesions of the knee joint.

It is necessary to differentiate tuberculosis drives first of all from the now rare syphilitic process in our country. With syphilis, radiographs, as a rule, show small bone periosteal layers at the epiphyseal ends of the bones, the patella is enlarged in volume - elongated and widened, in the tibia or less often in the femur there are gummous foci of destruction typical for syphilis, surrounded by a dense osteosclerotic shaft. There is no osteoporosis due to preserved joint function and painlessness. However, there are also predominantly synovial forms of syphilitic arthritis that radiologically exactly resemble long-term benign tuberculous hydrops or fungus, and a diagnostic error awaits a radiologist unfamiliar with the clinical picture.

With gonorrheal arthritis, which is also now rare, as with tuberculosis, the main radiological sign is significant osteoporosis. The most important distinguishing symptom of gonorrheal lesions is small subchondral lesions on the posterior surface of the patella, where tuberculous granulations in isolated form are never observed. A sharp narrowing of the joint space with smooth contours of the epiphyseal ends, the absence of deep destructive changes in the bones, periosteal layers, rapidly occurring ankylosis, especially of the patella, with an appropriate history and clinical picture(turbulent beginning, unusually severe pain) resolve the controversial issue in favor of gonorrhea.

And purulent prolonged arthritis (staphylo, streptococcal and pneumococcal) can resemble a tuberculous process in the knee joint, sometimes lasting a long time and benign. The radiologist has to differentiate between both diseases mainly in cases where the patient seeks medical assistance several years after a more acute course of the disease with contracture or ankylosis. The diagnosis is especially important here, since the treatment of both diseases is to a certain extent opposite. With purulent arthritis, there is either a significant osteomyelitic process in one of the bones, usually in the thigh, or, conversely, both bones are relatively little changed, that is, the epiphyseal ends are destroyed more superficially than in tuberculosis. In this case, bone defects are not located on the lateral parts of the epiphyses, as in tuberculosis, but precisely at the points of contact, i.e., in the central parts of the condyles. In addition, due to the complete resorption of the cartilage, the joint space is either completely absent, and bone ankylosis develops relatively quickly, or it is very sharply narrowed, and the capsule is not stretched, as in tuberculous gonitis.

In rare cases, damage to the knee joint in rheumatic and rheumatoid polyarticular disease also acquires differential diagnostic significance. The fact is that in practical work there are unusual forms of polyarthritis, which, although they affect several joints, from the very beginning mainly affect one of the large joints, usually the knee or hip joint. Clinical phenomena from the knee joint come to the fore so much that the disease of other joints is visible, and the process, essentially polyarticular, goes under the guise of tuberculous monoarthritis. A similar symptom is osteoporosis. With the process of the polyarticular type, however, such profound destructive changes never occur as with tuberculosis. The significantly narrowed joint space is bordered by uneven, but very sharply limited contours, in contrast to the blurred contours of tuberculous arthritis. At the edges of the epiphyses, a living productive bone reaction is usually expressed in contrast to tuberculosis. A more thorough anamnesis and radiography of other joints, revealing essentially the same changes, finally dispel diagnostic doubts.

Let us point out here the lesions of the joints that have only recently become known in the so-called periodic disease, which in themselves, in isolation from the general clinical picture, can be indistinguishable from tuberculous arthritis.

X-ray examination is the only simple and absolutely reliable means for differentiating tuberculous gonitis from partial wedge-shaped dissecting osteochondropathy of Koenig. The clinical differential diagnosis always leaves a certain amount of doubt, since partial wedge-shaped osteochondropathy can occur as intermittent, relatively benign, tuberculous hydrocele of the knee joint. On radiographs, a wedge-shaped, round or lenticular necrotic bone lesion located in typical place in the bony niche in the medial femoral condyle, has pathognomonic significance.

Chondromatosis of the joint, when the entire joint cavity is filled with many oval or multifaceted intra-articular loose bodies adjacent to each other with their facet-like surfaces, is also categorically excluded on the basis of x-rays. Let us take into account the possibility, albeit very rare, of calcification of rice bodies.

Gouty arthritis, which also simulates tuberculosis, is supported by typical marginal, sharply limited round defects in the bone and mainly on the articular edges of the epiphyses, small bone growths on their surface and the absence of more or less noticeable osteoporosis. But in large joints, and specifically in the knee, defects caused by the resorption of bone beams at the site of deposition of uric acid salts are relatively rare, and radiographs in most cases, with sufficiently clear clinical data, present a normal picture - an indication of soft tissue damage. Here, without a clinic, X-ray diagnostics are often helpless.

Changes in hemophilia, most often observed in the knee joint, are very poorly recognized before x-ray examination and are often mistaken for tuberculosis. Only in the case of acute initial hemorrhage into the joint cavity, radiographs do not reveal anything characteristic; there are only general symptoms of overfilling of the articular cavity with a pathological product. In typical cases, delicate shadows of blood clots soaked in lime appear in the joint cavity and capsule, the joint space narrows and, what is especially characteristic, in a typical place - in the intercondylar fossa of the femur and in the area of ​​​​the intercondylar tubercle of the tibia, where the cruciate ligaments are attached - are outlined extensive semicircular bone defects. Atrophy is usually mildly expressed. Far advanced forms resemble disfiguring osteoarthritis in their productive changes. In some cases, the lesions are multiple. It is therefore easy to exclude tuberculous arthritis.

From a radiological point of view, deforming osteoarthritis is the direct opposite of the usual picture of tuberculous arthritis. The articular contours of the epiphyses are sharply limited, the joint space is uniformly significantly narrowed, and at the edges of the epiphyses there are characteristic lush bone growths in the form of lips, ridges and spines. Osteoporosis is absent at all or only to a barely noticeable degree; ankylosis never occurs. Therefore, there is nothing easier than drawing a line between both diseases. But since deforming osteoarthritis is the final anatomical result of a wide variety of etiologically diverse diseases of the joints, tuberculous arthritis can lead to disfiguring changes. Such cases, the tuberculous nature of which has been impeccably proven, are by no means rare today. These cases are clinically very benign for many years, they cause little pain and do not particularly limit the function of the joint, they progress slowly, do not cause decay or fistulas, and, therefore, their course also resembles osteoarthritis. Clinical and radiological difficulties in recognizing these atypical forms of tuberculous gonitis are obvious.

An elementary task for the radiologist is to distinguish tuberculous gonitis from tuberculous arthropathy. Just the picture of huge shapeless calcifications of the capsule and ligamentous apparatus, completely incompatible with the idea of ​​tuberculosis of the joint, gives the right to discard the idea of ​​tuberculous arthritis at the first glance at the pictures.

Radiographs are also crucial for excluding new bone formations originating from the epiphysis or metaphysis of the bone and clinically simulating a “white tumor”. A true blastoma, for example osteogenic sarcoma, destroys only one bone over a large area, leaving the other unchanged; at the site of the tumor there is a continuous transparent defect or, conversely, an area of ​​darkening of the bone tissue; articular cartilage, even with very large tumors, remains spared.

An isolated bone cyst and the so-called giant cell tumor, which are often located in the distal end of the femur or proximal tibia and give the clinician a reason to suspect tuberculosis, are also easily rejected radiographically.

The differential diagnostic role of X-rays for tuberculosis and traumatic injuries of the knee is very different. With fresh traumatic synovitis, radiographs give the same symptoms, or rather, as few symptoms as with tuberculous dropsy, and cannot particularly contribute to elucidating the etiology of the disease. In other cases, when, some time after the injury, a subacute or chronic reactive articular process begins, clinically reminiscent of tuberculosis, photographs can bring some clarity. They, for example, unexpectedly indicate a separation of the intercondylar tubercle of the tibia or other more significant damage to the intra-articular ligamentous apparatus, incipient deforming osteoarthritis, etc., and this facilitates the clinic’s task.

The difficulties of distinguishing tuberculous gonitis and the so-called meniscitis, i.e., the consequences of a traumatic violation of the integrity of the lunate cartilage, if for some reason the anamnestic data are not clear enough, are very great. Essentially, the X-ray picture of this type of post-traumatic arthritis indicates a predominantly nervous nature of the disease, which develops after internal damage to the joint. In some cases, osteoporosis occurs quickly - after 6-8 weeks, regional osteoporosis of the small-focal (miliary) or nostril type, and then after 3-4 months, large-spotted piebald osteoporosis. Not to mention the fact that some areas of rarefaction can be mistaken for inflammatory tuberculous destruction, the entire x-ray picture of such osteoporosis cannot in itself be distinguished from osteoporosis due to tuberculosis. In the future, the resulting uniform osteoporosis brings the two diseases even closer together radiographically. Therefore, additional diagnostic tools must be mobilized, even complex ones, such as pneumoarthrography. In any case, in order to avoid serious therapeutic errors in the event of an incorrect diagnosis, both positive and negative, since treatment tactics for both diseases are seriously divergent, it is necessary each time to especially weigh the indications for an active or conservative method of treatment, for immobilization, for surgical intervention, for the use of massage etc., before an accurate, responsible diagnosis is flawlessly made. The long-term results of erroneous recognition and treatment here are very disastrous.