Tuberculosis of bones and joints in adults. Tuberculosis of bones and joints: symptoms, first signs and treatment. Treatment of bone tuberculosis

The content of the article

Osteoarticular tuberculosis serves as a local manifestation of a general tuberculosis infection of the body. In relation to the total number of tuberculosis diseases, bone tuberculosis lesions account for 3.4%. Until 1962, patients with osteoarticular tuberculosis were the main contingent among patients with extrapulmonary forms of tuberculosis. With the better organization of identifying individual localizations of the tuberculosis process, the incidence of osteoarticular tuberculosis ranks second after tuberculosis of the genitourinary organs, accounting for 19.4% of diseases with extrapulmonary tuberculosis, of which 2/3 are patients with active osteoarticular tuberculosis and 1/3 - with inactive.
Osteoarticular tuberculosis is currently observed mainly among adults, often among the elderly. The most common localization of the osteotuberculosis process remains the spine (35-40%), followed by the hip-femoral and knee joints (40%). Localization of the process in other bones and joints is 20%.
Before the use of BCG vaccination, antibiotics and chemotherapy, the percentage of patients with multiple forms of osteotuberculosis lesions reached 30. Currently, the percentage of these forms of the disease has decreased to 10-12, which forces in each individual case of multiple lesions to assume a different etiology of the process (infectarthritis, etc.). The combination of osteoarticular tuberculosis with an active pulmonary process does not exceed 3%.
The tuberculosis process in the bone occurs when the tuberculosis infection dissipates in the body through the blood and lymphatic vessels. The development of the osteotuberculosis process at the site of mycobacteria settling in the red bone marrow is facilitated by the high virulence of mycobacteria, the massiveness of infections, the weakening of the macroorganism by intercurrent diseases (measles, whooping cough, etc.), mental trauma, and difficult living conditions. Contact with tuberculosis patients, especially prolonged contact, is of great importance. The role of trauma is defined as revealing a latent tuberculosis process and exacerbating a quiescent one.
The sedimentation of Mycobacterium tuberculosis in the myeloid substance of the bone marrow leads to the development of perifocal inflammation with the reactive proliferation of nonspecific granulation tissue, in which lymphoid nodules and tuberculous tubercles are subsequently formed. Under favorable conditions of protection from the body, reactive inflammation manifests itself moderately; granulation tissue turns into fibrous tissue, penetrating the tuberculous tubercles, a scar is formed, and sometimes even the bone structure is completely restored. Under unfavorable conditions, granulation tissue grows, destroys bone (through lacunar resorption) and at the same time undergoes necrosis with cheesy degeneration in the center. A so-called primary focus, or primary tuberculous osteitis, forms in the bone. Cheesy necrosis remains unchanged for a long time or melts, forming a tuberculous abscess.
Primary tuberculous osteitis is localized predominantly in spongy tissue rich in myeloid bone marrow and blood vessels. Further spread of the process and its transition to the joint occurs gradually. The closer the lesion is located to the cortical layer of the bone, the faster its transition to the joint is possible. Bone lesions that arise in the epimetaphyseal regions remain unrecognized for a long time. They can spread towards the cortical bone and open into the joint or (in favorable cases) above the attachment of the joint capsule. Lesions located in the metadiaphyseal region of long bones remain isolated in most cases. As the bones grow, they move away from the growth plate and eventually regain normal bone structure.
When the spine is affected in children, primary tuberculous osteitis is localized in the center of the vertebral body, much less often in the arches, articular, transverse and spinous processes, in which the compact layer predominates. When the vertebral body is destroyed, the tuberculous granuloma spreads to the surrounding soft tissues, neighboring vertebrae are involved in the process, and a tuberculous abscess is formed. The spread of tuberculous lesions in the vertebral bodies leads to deformation of the spine, its kyphotic curvature, which is especially characteristic of childhood. In adults, due to the density of the bone-trabecular network, kyphosis does not reach large sizes; the tuberculous process spreads superficially, involving larger areas of the spine.
When the shoulder and hip joints are affected, a special form of the tuberculosis process occurs - dry caries, which is characterized by the absence of necrosis and abscess. Resorption of bone tissue occurs through granulation.
Damage to the joint capsule as the initial form of the process is very rare. As a rule, the joint capsule is affected secondarily as a result of the transition of the process from the bone. The development of the osteotuberculosis process depends on the age of the patient at the time of the disease. In young children, pronounced perifocal inflammation is observed with a predominant localization of the process in the diaphysis of the tubular bones, which is accompanied by a reaction of the periosteum. After the age of three, the course of the disease is less acute. The tuberculosis process is concentrated mainly in large joints and the spine. In adolescents, the osteotuberculosis process occurs with significant tuberculosis intoxication. It is often accompanied by active tuberculous changes in intrathoracic organs.
After the end of the growth period in adults, the vascular network becomes poorer, the growth cartilage disappears, the articular cartilage, which in childhood serves as a strong barrier that prevents the spread of the process, becomes thinner, and the trabecular network thickens. Therefore, the process in adults spreads superficially, but involves a larger part of the bone. The recovery process in adults is slowed down and proceeds with a much less favorable outcome than in childhood.

Clinic of osteoarticular tuberculosis

The early period of the disease at the time of dispersal of tuberculosis infection is not clinically possible to detect. This period manifests itself in the form of general symptoms of a functional disorder of the body and tuberculosis intoxication.
The first clinical and radiological manifestations of bone tuberculosis correspond to its initial form. They are expressed by difficulty in the function of the affected organ due to reactive nonspecific inflammation around the lesion, fatigue when walking, limb weakness, muscle hypotonia, changes in gait, forced position of the body, some stiffness of movements when the process is localized in the spine. Characterized by periodicity of clinical manifestations, quickly disappearing under the influence of short-term rest and renewing during exercise.
Recovery processes in the initial forms of osteoarticular tuberculosis are different. In some cases, the process passes without a trace or only the restructuring of the bone beams in the lesion remains, but despite the complete restoration of the lesion, persistent muscle atrophy may remain, spreading to the entire limb and to the long muscles of the back.
The slow development of a bone tuberculosis focus also results in a slow, gradual increase in clinical symptoms and the transition of the process to a minor form. Symptoms of the minor form are expressed by trophic tissue disorders, clear hypotension or muscle atrophy, and bone osteoporosis, characteristic of osteoarticular tuberculosis. A more pronounced paraspecific reaction in the joint in response to greater irritation of the bone lesion is manifested by thickening of the joint, some limitation of mobility in it in the direction of the muscle that is closest to the joint capsule or lesion. There is muscle tension in the affected area and limited mobility in the spine.
With timely treatment of a minor form of the process, inflammatory phenomena quickly disappear. Dystrophic changes in the tissues remain, and on the radiograph there is a focus in the bone, which does not always undergo reverse development. In some cases, it is only delimited by a dense bone shaft. In the center of such a lesion, sequestration and caseosis may remain.
Small forms in weakened patients, untreated or who started treatment late, gradually progress and turn into a pronounced form, which corresponds to the arthritic phase according to P. G. Kornev. Clinical symptoms intensify: the contours of the joint are smoothed, its volume is increased due to effusion, thickening of the joint capsule. In superficial joints there is a local increase in temperature compared to the healthy side.
With further progression of the process, the swelling of the joint increases, the bag filled with effusion stretches: the small vascular network and nerve roots are compressed. The first complaints of Ooli appear in the knee joint with a disease of the hip-femoral joint, in the hand and fingers - with damage to the shoulder joint, in the arms - with damage to the cervical spine, abdominal pain when the tuberculosis process is localized in the middle and lower thoracic regions, whooping cough - if the upper thoracic region is affected, etc. The mobility of the joint and spine is limited. The limb is established in a pathological position, which initially has the character of a protective “painful” contracture that prevents the mobility of the affected organ. As the tension of the bursa increases, the contracture also increases; joint mobility is limited. Local pain increases. This most acute period of the disease is accompanied by restless sleep (in children - night screams due to the disappearance of reflex contracture during sleep), loss of appetite, and an increase in body temperature to 38-38.5°. At this time, as a result of a sharp tension in the bursa, it is possible for it to break through and the process to spread to soft tissues, the formation of a tuberculous abscess and often fistulas, which always aggravate and complicate the disease.
All of the above symptoms are also observed in tuberculous spondylitis. Contracture with it is expressed by a violation of statics: torticollis, lateral curvature of the body; with a reflex contracture of the iliopsoas muscle or with a tuberculous abscess descending along the vagina of this muscle, lameness is observed. But tuberculous spondylitis, complicated by tuberculous abscesses and spastic paralysis, is especially long-lasting and difficult.
A tuberculous abscess in tuberculous spondylitis forms, as a rule, on the anterior surface of the vertebral bodies, exfoliating the anterior ligament; on the posterior surface, peeling off the posterior ligament, passes into the cavity of the spinal canal. Having destroyed the ligament, the tuberculous abscess spreads along the intermuscular and vascular pathways to a long distance from the initial lesion. With tuberculous spondylitis of the thoracic region, the abscess spreads upward; in the cervical region it is localized in the retropharyngeal space.
Spinal disorders in tuberculous spondylitis in the active stage of the process are formed under the influence of impaired blood and lymph circulation that develops in the vicinity of the tuberculous focus, less often - from pressure from a tuberculous abscess or sequester. Spinal disorders are clinically manifested by increased tendon reflexes, clonus of the feet and patella, spastic paresis or paralysis.
In a small percentage of cases, the tuberculosis process can develop acutely, which occurs when the contents of a bone lesion suddenly break through into the joint cavity. Absorption of toxic material from the joint cavity simulates an acute infection, which may be mistaken for infectious osteomyelitis. All symptoms of a pronounced form of osteoarticular tuberculosis refer to the moment of progression of the tuberculosis process, to its active stage, when extensive destruction occurs in the affected area and degenerative changes in all tissues and organs.
The duration of the active stage largely depends on when treatment is started. The process moves into the stage of loss of activity slowly and gradually. All indicators of the patient’s general condition improve or normalize, pain stops, joint swelling disappears, contracture straightens; The amplitude of movements in the affected organ increases, but during a destructive process in the joint it is never restored to normal due to a violation of the normal relationships of the articular surfaces, cicatricial adhesions, cicatricial degeneration of the joint capsule, leading to arthrogenic contractures.
By the time the bone process loses activity, tuberculous abscesses either resolve or become denser and calcified. Deformations resulting from bone destruction, degenerative processes of subcutaneous tissue, and muscle atrophy remain unchanged.
Clinical symptoms in the stage of loss of activity are poor, but morphologically, reparation predominates at this stage: delimitation of the lesion and some restoration processes in it. At the same time, if treatment is interrupted during this period and the affected organ is prematurely loaded, conditions are created that disrupt reparative processes and can transform a benign process into its malignant form.
In the calming stage, inflammatory changes and muscle rigidity completely disappear. There are no active changes in other organs available for study. There are only those residual deformations that are formed in the active stage of the pronounced form of the process and are accompanied by large destruction of bone tissue and degeneration. In the calming stage, the patient should be transferred to another regimen, treatment measures should be stopped, and a load should be assigned to the affected organ. Therefore, in addition to comprehensive studies of the patient, a time test is also necessary, during which an increase in reparative phenomena and a decrease in dystrophy will be revealed.
In the presence of an unresolved tuberculous abscess, the stage of subsidence of the process can be diagnosed only with dense abscesses detached from the main bone lesion.

Diagnosis of osteoarticular tuberculosis

The basis for diagnosis is clinical, radiological and laboratory tests. Based on the totality of all data, the etiological diagnosis is clarified.

Clinical research methods

They clarify the medical history of the disease, find out whether the patient is infected, contact with a patient with tuberculosis, the condition of the intrathoracic organs, and the living conditions in which the patient is located (at home, at work, at school). The duration of the disease and its first manifestation, the frequency of symptoms, their gradualness or severity are determined; find out the nature of the treatment and its results (antibiotics). Clarify the patient’s complaints that led him to the doctor; In adult patients, signs of the disease in childhood are determined.
The examination of the patient begins from the moment he enters the doctor’s office. They perform a community examination of the patient. The child must be stripped naked. Examine the condition of the skin, lymph nodes, muscles of the back and limbs, the presence of scars, tuberculids. Pay attention to posture, position of the patient (natural or forced), curvatures, vicious positions, swelling of tissues, function of the affected organ compared to the healthy side, mobility of the spine, changes in gait, lameness.
By palpating simultaneously on symmetrical areas of the healthy and diseased limb, the area of ​​local damage is clarified. Over superficially located joints, local skin temperature, thickening of the skin in the joint area, swelling of tissues, thickening of the subcutaneous fat layer (Alexandrov’s symptom), muscle tone, their tension, joint volume, relationship of bones, density of the joint capsule, its contents, condition of the skin are determined. over the tumor, tissue pain.
By measuring with a centimeter tape, the length of the limb and the difference in the thickness of its individual parts are determined; An inclinometer determines the degree of mobility in the joint and its position. For the correctness of the measurements, you should compare the diseased and healthy sides in a strictly symmetrical position, using symmetrical points. The true length of the limb is measured from the top of the greater trochanter to the end of the ankles (anatomical length); relative shortening (i.e., true shortening plus the amount of upward displacement of the femur) - from the anterosuperior iliac spine to the lower end of the medial malleolus. The apparent functional change in the lower limb, its length, due to one or another contracture, is measured with parallel legs (the position of the legs necessary for walking) from the navel to the inner ankle of each leg.
The range of motion is established for both active and passive movements. All types of mobility in a given joint are checked. It is imperative to start movements from a healthy joint, performing them without the slightest violence. In this case, an early symptom of limited mobility may be detected - a symptom of Lannelong muscle vigilance: instead of the normal smooth transition of the limb from one position to another, intermittent step-like movements occur.
The mobility of the spine is determined by slowly bending the patient forward with outstretched arms until the fingers touch the surface of the floor, then by the same slow extension and deviation of the torso posteriorly. The doctor's hand checks the uniformity of mobility of each spinous process. In severe cases of spondylitis, the patient refuses to bend and only squats, resting his hands on his knees with the spine motionlessly straightened. Less severe limitation of mobility is easier to detect by placing the baby stomach down with the arms extended at the sides. The doctor, with one hand raising and lowering the patient’s legs, bent at the knee joint, simultaneously checks the uniformity of movement of each spinous process with the other hand. In a patient with spondylitis, knee reflexes, clonus of the patella and feet, pathological reflexes are examined, and in case of damage to the cervical and upper thoracic spine, also mobility and muscle strength of the arms.

X-ray diagnostics

X-ray diagnostics for osteoarticular tuberculosis is the main method after the clinical one. A lag between the X-ray picture and the clinical picture is typical for bone tuberculosis, especially in adults. X-rays of the affected area are taken in two mutually perpendicular projections: direct and lateral. Paired joints are filmed on the same film under the same technical conditions. On the radiograph, bone trabeculae and the contours of soft tissue shadows should be clearly visible. The central beam of the x-ray tube should pass through the center of the suspected lesion. To monitor the dynamics of the process, radiography should be repeated for initial and minor forms after 2-3 months, for severe forms - every 4 months.
When reading a radiograph, a strict sequence should be followed: first, osteoporosis of the bone on the affected side is determined in comparison with the healthy side, the contours of the bone, the thickness of the cortical layer, changes in the periosteum are examined, then the articular or intervertebral space is determined, its expansion or narrowing, the ratio of the articular surfaces (or vertebral bodies ), their shape and outline, focal changes in the bone, their localization, shape, edges, their contents (caseosis, sequestration), study the shadow of the bursa, outlines of muscles, intermuscular layers, additional shadows (abscesses,
hemogenicity of their shadows or granularity, etc.). Each form of the bone tuberculosis process has characteristic radiological features.
In the initial form, mild osteoporosis is noted. The earliest stage of primary osteitis is manifested by a confused pattern of bone trabeculae or a focus of local osteoporosis without clear delimitation, later by a delimited bone lesion, an expanded shadow of the bursa and expansion of the intermuscular layers.
In small forms, osteoporosis is more clearly visible. In children, there is an increase in the ossification nucleus of the epiphysis due to its faster growth under the influence of perifocal irritation, expansion of the shadow of the bursa and intermuscular layers.
When the cortical layer is intact, initial changes in the bone cannot be detected by conventional radiography. They can only be assumed by the more severe local osteoporosis; later, a confused pattern of a network of bone trabeculae is revealed, and even later a bone cavity is revealed.
With a pronounced form in the active stage, there is clear osteoporosis, which, as the process progresses, can reach extreme degrees, when bone trabeculae become indistinguishable, and the cortical layer appears in the form of a thin border.
With such bone conditions, minor muscle strain can lead to a pathological fracture. Bone tuberculosis is characterized by widespread osteoporosis throughout the bone. It is difficult to detect a small degree of osteoporosis in the spine due to its irregularity; in addition, it is covered by a number of organs with different blood supply and different air capacity.
Therefore, the earliest sign is a narrowing of the intervertebral space, indicating a violation of the integrity of the intervertebral cartilage and damage to the vertebral body. Narrowing of the intervertebral space on a direct radiograph may be false; true narrowing is visible on both direct and lateral views.
The progression of the process is manifested by blurring of the contours of the articular surfaces, and subsequently by a violation of their integrity. During the loss of activity stage, no further bone destruction is observed; a more dense network of bone trabeculae and contours of the bone lesion is revealed. In the stage of a quiescent process, osteoporosis sharply decreases; the contours of the bones are clearly marked. Soft tissues are calm. The density of the bone structure completely returns to normal only in initial and minor forms, after several years
normal functioning of the limb. In a severe form with destruction of the articular ends of the bones, the bone remains osteoporated compared to the healthy side.
The X-ray picture of a tuberculous abscess varies depending on its freshness and location, especially when the spine is affected. A fresh abscess is homogeneous and differs only indirectly - by the contours of the soft tissue adjacent to it or by deviation from the normal location of the muscles, trachea, and ligamentous apparatus. Such abscesses can completely resolve. The shadow of an older abscess thickens and acquires a motley, speckled pattern, indicating the presence of still active elements of tuberculous granulations in it. Gradually, the shadow of the abscess turns into a uniformly speckled shadow due to its complete calcification. Such abscesses rarely resolve.
Layer-by-layer radiography serves as an additional research method. It makes it possible to detect initial changes located deep in the bone tissue, not visible on conventional radiographs. Due to the small size of the lesion in the early stage of its development, tomograms should be spaced no more than 0.5 cm apart; the examination should be carried out throughout the entire depth of the bone.
Survey radiographs of the entire skeleton in children with an active bone process in rare cases reveal the presence of multiple so-called silent lesions in the bones. From the stage of loss of activity, new lesions are not detected.

Laboratory research methods

The same clinical and biochemical studies are carried out as in patients with other localizations of tuberculosis. Tuberculin tests are of particular importance for patients with bone tuberculosis. Positive tests indicate that the patient is infected, but do not yet prove the tuberculosis etiology of the disease.
In the diagnosis of unclear cases, negative tuberculin tests are of great importance if they do not coincide in children with a number of intercurrent diseases (measles, whooping cough, pneumonia), or in severely weakened children. If Pirquet's reaction is negative, an intradermal Mantoux IV test is given. If these tests do not provide clarity, use the subcutaneous Koch reaction with tuberculin of the 2nd dilution with preliminary measurement of body temperature every 3 hours before and after the test and a general blood test, repeated 24 and 48 hours after the test.
During bacterioscopic examination of joint effusion and pus from a tuberculous abscess, tuberculous mycobacteria are very rarely detected; they are more often detected when inoculated on special nutrient media. The most reliable diagnostic technique is inoculation of pus or effusion from the joint cavity into guinea pigs. The biopsy method is valuable only if the patient has a typical tuberculous tubercle, which cannot always be detected with limited damage to soft tissues.
Cytodiagnostic data of regional lymph nodes are considered positive if they contain lymphoid and epithelioid tubercles, accumulations of caseous masses and pronounced hyperplasia of lymphoid tissue.
The cytogram of joint effusion in tuberculosis is of the lymphocytic type, and in case of nonspecific infection it is of the neutrophilic type. A cytological examination of pus in tuberculosis reveals a small number of cellular elements with a slight predominance of neutrophilic leukocytes over lymphocytes. With secondary infected pus, a large number of cells with a predominant content of neutrophils are determined.
In the bone marrow of patients with osteoarticular tuberculosis, changes specific to tuberculosis are relatively rare.

Treatment of patients with osteoarticular tuberculosis

All therapeutic methods should be aimed at quickly eliminating the active stage of the osteotuberculosis process, preventing its progression, destruction, formation of caseosis and restoring normal or close to normal function of the affected organ. To successfully treat a patient, it is necessary to provide for various possibilities for the development of the process, take into account the body’s response to infection, the form and stage of the process, the duration of the disease, the condition of the internal organs and lymphatic system.
Treatment methods for a patient with bone tuberculosis consist of nonspecific restorative agents aimed at increasing the body's resistance, and specific agents aimed at the pathogen. The main general activity is sanitary and orthopedic treatment. It consists of extensive use of physical methods, a properly established daily routine and proper nutrition. Climatic factors are of greatest importance: air and sun.

Air treatment

Prolonged exposure to fresh air affects pulmonary ventilation. Air baths have a thermal and mechanical effect on the naked surface of the body. For round-the-clock stay of patients in the open air in summer or spring-autumn until the first frost and even in winter, special areas, open pavilions, and verandas are built. Glazed terraces are impractical and do not provide sufficient access to fresh air.

Sun treatment

Sun treatment as a factor of irritant therapy is carried out in the form of general light irradiation of the entire body with direct rays (general sunbathing) or diffuse radiation (light-air baths) in the shade of protective screens or trees.
The purpose of sunbathing should be individualized. They begin in the early morning hours, gradually increasing both the time spent in the sun and the size of the illuminated body surface (starting with the lower extremities). The maximum duration of sun treatment can reach up to 3 hours in the middle zone, and up to 1.5-2 hours in the south.
Solar radiation is dosed in accordance with the solar radiation dosimetry system, with a dose unit equal to 5 small calories per minute per 1 cm3 of body surface perpendicular to the sun's ray. Sunbathing starts with one dose, or 5 calories, gradually increasing to 30-50 calories. Dosimetry takes into account air temperature, air movement, and humidity.
Sun treatment requires strict monitoring of the patient’s well-being. The reasons for reducing the time of sunbathing are fatigue, loss of appetite, nervous agitation, increased heart rate, weight loss, sudden stress, and poor sleep.
During Suntherapy, the patient's head must be replaced. After sun and water baths, dousing, wet rubbing, and shower are recommended. In sanatoriums located on the seashore, sea bathing is used.
Contraindications to sun treatment: general severe condition, exhaustion, amyloidosis, diarrhea, infectious diseases, active processes in intrathoracic organs.
Basically, treatment of a patient with bone tuberculosis is carried out at his place of residence. At the same time, a change in climate to a more gentle or more irritating one has an undoubtedly beneficial effect.

Nutrition for patients with osteoarticular tuberculosis

The nutrition of patients with osteoarticular tuberculosis must meet all the nutritional requirements for patients with tuberculosis. However, it must be remembered that in a patient with osteoarticular tuberculosis, who has been on bed rest for a long time, the function of the digestive organs is weakened, peristalsis is sluggish, so his food should include substances that enhance peristalsis.

Daily regimen of a patient with bone tuberculosis

A strict daily routine with a proper change of rest and activity is necessary. In children's institutions, the daily routine includes school and extracurricular activities conducted by a special staff of teachers.
In sanatoriums for adults, the daily routine also includes activities that are mandatory: work processes, lectures, improvement of knowledge, correspondence education, etc.
The most important component of the sanatorium regimen is sleep patterns. It requires differentiated organization both at night and during the day, depending on the age of the patient.

Antibacterial therapy

Antibacterial therapy is carried out against the background of sanatorium-orthopedic treatment, which is the basis of the entire complex of therapeutic measures. Antibacterial treatment of synovial and fresh bone forms of the process before the formation of caseosis or with fresh abscesses is especially effective. The success of antibacterial therapy depends on the earliest possible start of its use, sufficient duration and continuity of treatment at optimal dosages. A reduction in the duration of the active stage of the process, stopping its progression, restoration of the bone structure in the lesion, and a decrease in complications were noted.
Treatment is carried out with a combination of tuberculostatic agents. In the acute course of the process, the threat of a breakthrough of the lesion into the joint, three drugs are prescribed for 1.5-2 months, and then they switch to two drugs in optimal doses. A compacted course is carried out until the process loses activity. On average, treatment is continued from 6 to 12 months, depending on the general condition of the patient, the nature of the process and the effectiveness of treatment. For osteoarticular tuberculosis, the general principles of treatment are the same as for tuberculosis of other organs.
Streptomycin. The main indicators for the use of streptomycin are the activity of the osteotuberculosis process, the severity of the course and the presence of a significant perifocal reaction. Streptomycin has the greatest effect in the treatment of initial forms with the presence of a primary complex in the lungs and small forms of osteoarticular tuberculosis, where there are still no caseous foci and destructive changes. Duration of treatment: 2-3 months for initial forms of the process, 3-5 months for minor forms and 7-10 months on average for severe forms with complications. Streptomycin penetrates poorly into caseous lesions due to their poor vascularization.
The daily dose for children is 0.02-0.03 g per i kg of patient weight. Administer intramuscularly once a day. The average daily dose for children under 3 years old is 0.2-0.3 g, 4-7 years old - 0.3-0.4 and 8-12 years old - up to 0.6 g. Adults are prescribed up to 1 g per day.
Streptomycin in combination with PAS. The average daily dose of PAS is 0.2 g per 1 kg of patient weight. The daily dose for children under 3 years old is 1.5-3 g, 4-7 years old - 3-4 g, 8-12 years old - 4-6 g. Adults are prescribed 8-12 g per day in 3-4 doses. The duration of treatment depends on the clinical effect and tolerability of the drug.
PAS is always prescribed in combination with other drugs. If PAS is poorly tolerated, passomicin (dihydrostreptomycin + PAS) is used intramuscularly at 0.4-1 g per day. It is tolerated for a long time, without side effects.
A particularly important role in the treatment of osteoarticular tuberculosis belongs to drugs and cotinic acid (tubazid, ftivazide, metazide), which have the ability to penetrate into the focus and tuberculous abscess, the resorption of which is significantly accelerated. The dose of ftivazid is 0.03-0.05 g/kg in 1-3 doses. The dose of tubazide is 2 times less. When tubazid and ftivazid are combined with streptomycin and PAS, the therapeutic effect is enhanced.
Metazide replaces tubazide with long-term use; dose for children is 0.02-0.03 per 1 kg of weight, for adults the daily dose is 1 g.
When choosing antibacterial drugs, it is necessary to keep in mind the form of the process, the tolerability of the drugs, and data on the resistance of Mycobacterium tuberculosis. Along with first-line drugs, second-line drugs and new drugs are used in generally accepted dosages.
In severe cases, three drugs are prescribed for 3-4 months, then two antibiotics - streptomycin and tubazid - for 3-4 months. After this, streptomycin is discontinued and tubazide is prescribed in combination with one of the drugs, treatment with which is continued until the process loses activity when physical therapy is applied to the affected organ.
In case of secondary infection, fistula tuberculosis, infected tuberculous abscesses, discharge from the fistula or pus from the abscess, or mucus from the pharynx is examined for resistance to antibiotics and a course of treatment is carried out with appropriate drugs to which the patient is sensitive.

Methods of nonspecific therapy

In a patient with weak resistance of the body, with long-term and sluggish ongoing processes, to influence the general condition, transfusions of small doses of blood (50, 70, 100 ml) of the same name or 0 (I) group are used after 4-7 days, 10-12 transfusions per course . For patients with increased sensitization of the body to tuberculosis infection, desensitizing therapy with a 0.25% solution of calcium chloride intramuscularly or calcium gluconate is indicated. In young children with symptoms of rickets, antirachitic treatment is mandatory.

Hormone therapy

Hormonal therapy is used only in combination with antibacterial drugs with strict adherence to the sanatorium-orthopedic regimen.
Antibacterial-corticosteroid therapy is indicated for patients with tuberculosis intoxication accompanied by functional disorders of the adrenal cortex in various
forms and stages of osteoarticular tuberculosis; with an active osteotuberculosis process with low effectiveness of antibacterial therapy after 3-6 months from the start of treatment; with homogeneous abscesses without signs of calcification; with short-term paralysis caused by circulatory disorders in the spinal cord, perifocal edema or compression by a fresh abscess; with cicatricial changes in the joint capsule no more than 2 years old.
If the patient has decreased function of the adrenal cortex or its rapid depletion, a negative Thorne test, replacement therapy with hydrocortisone and prednisolone is used.
Treatment with cortisone in children start with 12.5 mg; daily the dose is increased by 12.5 mg and adjusted to the optimal dose, individual for each patient, which is left for l.5-2 weeks. Optimal dose for children: 2-5 years old - 25 mg, 6-8 years old - 37.5 mg, over 8 years old - 50 mg. Treatment is completed with descending dosages of cartisone for 10-14 days.
Treatment with ACTH. Doses for children 2-5 years old - 10-15 units, 6-8 years old - 20 units, over 8 years old - 20-30 units per day; for adults - 40 units per day. The duration of courses for cortisone and ACTH for initial and minor forms is l.5-2 months, for severe forms - 2.5-3 months. Hydrocortisone is used intra-articularly.
To liquefy calcified tuberculous abscesses, DOXA is used every other day in a 0.5% oil solution: for children 2-5 years old - 0.3-0.4 g, for older people - 0.5 g.
Vitamin therapy carried out in order to eliminate the deficiency of B vitamins: Bi, B2 and especially B6, in case of intolerance to GINK derivatives and the side effects caused by them.
Therapeutic exercise (physical therapy) necessarily included in the complex of therapeutic measures. The goal of gymnastics during the active period of the disease is a general effect on the body to activate all its functions. It has the character of general hygienic gymnastics without participation in the movements of the affected organ.
When the activity of the process is lost, exercise therapy aims to strengthen the ligamentous-muscular system and restore function in the affected organ. Measured movements in the affected joint and spine are carried out with a gradual increase in load. Massage the muscles of the affected limb and back. By preserving the composite surfaces or their marginal destruction through the use of exercise therapy, ozokerite therapy, and pine baths, normal joint function or useful mobility in it is achieved.
When the process subsides, the main task of exercise therapy is to develop correct posture and rhythmic gait.
If the patient gets out of bed on crutches, exercise therapy is performed in a lying position. Patients lifted without crutches do exercise therapy while standing with great care, gradually increasing the load; At the same time, general salt-pine baths are used, locally - ozokerite (for the fastest restoration of movements) and massage is required.

Local treatment of osteoarticular tuberculosis

In the active stage, continuous long-term rest, unloading and immobilization of the affected organ are necessary. A special bed with wide metal wheels, which can be easily moved without disturbing the patient’s calm position, plays a major role in local treatment. It is equipped with a metal frame on which a special tight mattress is placed (a mattress for children consists of three parts).
In the initial stage of the disease, the patient is placed on the bed and secured with a soft bra-fixator. For stricter observance of rest in case of tuberculosis of the spine and hip-femoral joint, a plaster bed is used; if the knee joint or foot is affected - a plaster splint. The plaster crib accurately follows the shape of the back and grips the child’s head and lower limbs. In adults, depending on the location and stage of the process, it can be of different lengths: with spondylitis it reaches only the greater trochanters, with coxitis it covers only the affected limb. The crib is covered with a thin cover; the patient is placed in it naked. Clothes are placed over the crib. The patient remains in the crib until the process loses activity. If the limb is prone to contracture, traction with a small load along the long axis of the thigh and lower leg is added to the plaster bed.
It is necessary to constantly monitor the correct installation of the pelvis, the position of the feet, protecting them from pressure with a blanket, eliminating sagging of the knee joint, and placing a sand roller under the upper third of the shin. During the painful period of the process, the most complete rest of the affected limb is achieved with a circular plaster cast, covering two healthy joints adjacent to the affected ones, and in especially acute cases, the thigh on the healthy side to the knee. At the end of the painful period, the patient is transferred to a plaster bed. When the osteotuberculosis process subsides, the patient with the initial and minor form rises without a corset, splint or crutches. In severe forms, when there is a violation of the ratio of articular surfaces, deformities, residual tuberculous abscesses, patients are discharged in removable orthopedic devices.
Patients with tuberculosis of the cervical spine are placed in a plaster bed after first applying a Shants collar. Kyphosis in spondylitis is corrected by placing a cotton pad in a plaster bed corresponding to the affected area, gradually increasing in thickness. A patient with corrected kyphosis rises in a corset. The corset should prevent the upper segment of the spine from bending forward. Release from a splint or corset is dictated by the state of the local process, regularly checked clinically and radiographically.

Surgical treatment of osteoarticular tuberculosis

With a long course of the osteoarticular process, caseous masses and sequestra are formed in the primary bone lesion, which are difficult to reverse, hinder the restoration of vascularization and bone regeneration and are not only the main obstacle to eliminating the disease, but also the cause of further spread of the process. This implies the need for surgical intervention depending on the form and stage of the process in the form of radical, auxiliary and corrective operations (P. G. Kornev).
In focal forms of the process if the effectiveness of complex treatment is delayed, their timely removal is indicated through a radical prophylactic operation - necrectomy, which prevents the transition of the process to the joint and deformation of the joint. In case of tuberculous spondylitis, necrectomy can save the vertebral body from destruction.
When tuberculous osteitis passes to a joint It is indicated, under the protection of antibacterial therapy, intra-articular removal of the bone lesion (intra-articular radical-restorative necrectomy) with sparing treatment of the synovial membrane (P. G. Kornev), which makes it possible to preserve the function of the limb. In a pronounced form of the process with limited destruction of the articular surfaces, but with the preservation of their relationships and in the presence of bone lesions in the stage of loss of activity or subsidence, economical resection of the joint is performed as the final stage of complex treatment.
In case of severe destruction of the joint with a violation of the relationship of the articular surfaces, the patient is subject to atypical, reconstructive resection of the joint.
In the quiescent stage of the process, surgical interventions of a therapeutic and auxiliary type are also performed to correct anatomical and functional disorders as an additional method to radical operations on tuberculosis foci: osteoplastic fixation of joints - arthrodesis; for tuberculosis of the spine - spinal fusion, which is the final stage of treatment of tuberculous spondylitis with a large violation of the relationship of the vertebral bodies.
Currently, anterior spinal fusions have acquired particular importance as they provide more favorable static-mechanical conditions for restoring the support ability of the spine. Anterior spinal fusion is usually combined with necrectomy of the vertebral bodies or economical resection of adjacent surfaces of the vertebral bodies.

Surgical treatment of complications

Tuberculous abscesses. Puncture of a tuberculous abscess prevents the absorption of tuberculous toxins from the abscess, prevents its calcification and the possibility of breakthrough. Puncture of the abscess must be carried out under strictly aseptic conditions, from the overlying healthy tissue, in order to prevent the formation of a fistula tract. Streptomycin is injected into the abscess cavity. If a puncture fails to eliminate a tuberculous abscess, it is necessary to excise it (abscessectomy) together with the capsule; such excision is indicated mainly for joint damage.
In case of tuberculous spondylitis, the abscess is dissected and its inner membrane is removed (abscessotomy). This operation is complemented by removal of the bone lesion in the vertebral body along the tuberculous abscess.
Fistulas. An effective way to treat fistulas that do not respond to antibiotic therapy is shortening fistulotomy.

Spinal disorders in tuberculous spondylitis

Increased reflexes, clonus of the feet and patellas require careful rest of the patient in a plaster bed.
For reflex spastic contractures, warm baths, light massage of the leg muscles, and light active and passive movements are prescribed. For stable neurological symptoms that are not amenable to complex treatment within 4-6 months, surgical intervention is indicated - decompression of the spinal cord by hemilaminectomy, in most cases accompanied by necrectomy of the vertebral body and abscessotomy.
Surgical treatment should be carried out in a sanatorium-type hospital, where the patient will continue treatment after surgery.
tive intervention until the end of the recovery processes in the lesion.

Rehabilitation of patients with osteoarticular tuberculosis

Currently, the main task of treating a patient with osteoarticular tuberculosis is to cure the process with complete restoration of the function of the affected organ in order to return the patient to normal living and working conditions. In late-diagnosed or untimely treated patients with persistent dysfunction of the affected organ, ability to work can be achieved through a set of medical, professional and social measures, united by the term “rehabilitation”.
Medical rehabilitation is aimed at achieving the fastest loss of process activity in order to preserve normal function of the affected organ and restore the patient’s full ability to work in any profession. Medical rehabilitation is achieved through the use of orthopedic, surgical, medications, exercise therapy, and physiotherapy. An important point in rehabilitation is continuity and phasing in the treatment of restoration of lost function with a gradual transition from a gentle to a normal rhythm of life.
Vocational rehabilitation in childhood pursues the development of certain rules of behavior, discipline in the classroom during lessons, in labor classes, the purpose of which is to teach the child labor skills.
Professional rehabilitation of adult patients should be aimed at readapting the body to useful work, initially strictly dosed, with a gradual transition from a gentle regime to the normal rhythm of life.
In patients with impaired function of the affected organ, a correctly selected type of work helps restore lost function and develop compensatory devices.
Social rehabilitation carried out from the first days of the patient’s admission to the hospital. In a children's group, social rehabilitation includes the formation of social relations between children, labor obligations, participation in group activities and the work of a pioneer organization, and the aesthetic development of the child.
For adult patients who have lost their ability to work to one degree or another, social rehabilitation consists of preparing them for new professions available to them due to health reasons, in which they can be used on an equal basis with healthy people.
Rehabilitation of patients with osteoarticular tuberculosis is carried out by medical and teaching staff. The doctor must monitor the patient’s ability to work and, if necessary, promptly direct him to a lighter type of work, which will help the patient maintain his ability to work longer.

Differential diagnosis of osteoarticular tuberculosis

Errors in recognizing osteoarticular tuberculosis, especially its early diagnosis, are due to the great similarity of clinical symptoms in the initial stages of many diseases that are often encountered. Widespread, not always prescribed, use of antibiotics contributes to the manifestation of atypical forms of the disease with mild symptoms.
Diagnosis of initial and small forms of the process is especially difficult. Therefore, to clarify the etiology of the disease it is necessary
Use all diagnostic methods related to osteoarticular tuberculosis.
Differential diagnosis should be carried out with inflammatory diseases, non-inflammatory diseases and tumor processes.

Tuberculous spondylitis

Osteomyelitis: acute onset, abscesses, fistulas. It is very difficult to differentiate from tuberculosis.
Post-typhoid spondylitis: acute pain; take into account the anamnesis. The X-ray shows brackets fusing two vertebrae.
Grisel's disease: after an acute infection of the nasopharynx, subluxation of the first cervical vertebra (in children). Forced position of the head. There is no contracture of the neck muscles. An anterior radiograph taken through the mouth reveals the difference in the width of the joint space between the first and second cervical vertebrae.
Congenital torticollis in children: clinically contracture of the sternocleidomastoid muscle. There are no changes on the x-ray.
Congenital kyphosis and scoliosis (in children): full elasticity of the back. The x-ray shows various defects of the vertebral bodies.
Osteochondropathy of the ossification nuclei of the vertebral bodies: apophysitis, fatigue, mild back pain, muscle rigidity. The radiograph shows characteristic marginal defects with clear contours in the area of ​​the anterior corners of the bodies of several vertebrae in the absence of focal changes.
Calvet disease (in children): aseptic subchondral necrosis. The x-ray shows expansion of the intervertebral discs, flattening and compaction of the bodies of one vertebra.
Juvenile kyphosis (Scheerman-May disease): fatigue, difficulty moving, large radius kyphosis. The radiograph shows segmented ossification nuclei.
Senile kyphosis: X-ray shows deformation of the bodies, absence of destruction.
Rachitic kyphosis (in young children): often fixed. There is no damage on the x-ray.
Spondylitis deformans: pain, limited mobility of the back without muscle rigidity. The x-ray shows deformation of the bodies, bone growths.
Spondylolisthesis: persistent pain in the lumbar region. The X-ray (lateral) shows slipping of the V lumbar vertebra.
Ankylosing spondylitis (Bechterew's disease): pain in the lumbar and sacrococcygeal region. Gradual development of immobility of the spine, spreading upward. X-ray shows bony fusion of the vertebrae; ossification of ligaments. Narrowing of the sacroiliac joints.
Traumatic injuries: compressive fracture of the vertebral body, acquiring a wedge-shaped shape with clear contours and an unchanged disc.
Benign tumors: hemangioma (on a radiograph - thickening of the trabecular network with ring-shaped clearings), osteoma, osteochondroma (rare).
Malignant neoplasms are most often observed in the lumbar region. Sharp radiating pain. The x-ray shows a decrease in the vertebral body and an unchanged intervertebral space.

Joint damage

Osteomyelitis: acute onset, faster than in tuberculosis, delineation of the lesion, sclerotic contours, periosteal reaction. With epiphyseal osteomyelitis - a violent onset, abscesses. The radiograph shows a sharp periosteal reaction.
Rheumatic arthritis: history of frequent sore throats, tonsillitis, heart changes. Very rarely, one joint is affected (usually the knee).
Infective arthritis: characteristic cytology, severe limitation of mobility, changes in articular cartilage.
Gonorrheal arthritis: sharp pain. Heat. The radiograph shows sharp, limited osteoporosis, rapid melting of articular cartilage, early formation of bone ankylosis.
Bursitis of the knee and shoulder joints; pain, limitation of movements; There is no muscle atrophy. The X-ray shows a tumor not associated with the bone. Deposits of lime salts can be found in the joint capsule of the shoulder joint.
Traumatic hemarthrosis of the knee joint is determined by long-term observation and anamnesis. In case of hemophilic hemarthrosis in stale cases, the radiograph shows a bone defect in the intercondylar space.
Arthritis deformans in the elderly: pain that worsens at rest and when moving. The radiograph shows deformation of the articular ends.
Coxa vara in children: pain, greater trochanter protruding outward. The typical x-ray appearance is a steeply curved neck.
Perthes disease (juvenile osteochondropathy): pain, limitation of abduction and rotation in the hip joint. The radiograph shows preservation or expansion of the joint space; compaction of the ossification nucleus of the femoral head or its fragmentation.
Schlatter's disease: osteochondropathy of the tibial apophysis, pain, local swelling. A lateral radiograph shows an enlarged apophysis with a focus of local osteoporosis.
Partial osteochondropathy of the medial femoral condyle, pain, effusion. The radiograph shows a lenticular bony lesion along the edge of the inner femoral condyle.
Osteochondropathy of the scaphoid bone (Köhler's disease I): reduction in its size, hardening, local pain and swelling. Typical radiograph.
Osteochondropathy of the II tarsal bone (Köhler's disease II): the same symptoms as with osteochondropathy of the lunate and scaphoid bones.
Isolated bone lesions are differentiated from fibrous osteitis, Brody's abscess, osteoblastoclastoma, and osteoid osteoma. The radiograph shows the localization of lesions in the metaphysis; sclerotic bone surrounding the lesion; absence of osteoporosis.
Eosinophilic granuloma: a large multi-scalloped lesion, poorly defined, against the background of unchanged bone tissue.
Cortical defect (in children): most often in the area of ​​the knee joint in the metaphysis or metadiaphysis, never passes the growth zone. Asymptomatic. On an x-ray, it appears on the contour of the bone in the form of a clear, thin strip of sclerosis.
Malignant tumors. Sarcoma: observed mainly in the metaphysis. Sharp pain that is not relieved by riokoe in a plaster cast. The radiograph shows a blurred bone pattern, a break in the cortical layer, and bone growth from the periosteum. Spread of tumor to soft tissue.
Ewing's sarcoma (in children): course in the form of an acute inflammatory process. First the swelling, then the pain. Temperature up to 39°, not reduced by antibiotics. On the radiograph in the diaphysis there is an oval-shaped focus of destruction without clear boundaries, surrounded by a compact substance stratified into a number of plates (layered structure). Early differential diagnosis of Ewing's tumor with an inflammatory process is almost impossible.

Outcomes of osteoarticular tuberculosis.” Patient's ability to work

Currently, as a result of the use of complex therapy with inclusion and surgical methods, the final outcome of the disease with osteoarticular tuberculosis is the cure of the tuberculous process. Three types of cure are observed, depending on the timely detection of the disease and its correct comprehensive treatment.
Type I- complete cure, when almost no traces remain of the osteotuberculosis process after the end of treatment (after 4-5 months), either clinically or radiologically. This occurs mainly in the initial forms of the disease. This type of cure also includes primary synovial forms of the process.
Type II- cure with deformation of the joint (or spine), but without functional impairment. In tuberculous spondylitis, this is a bone block between two vertebrae, which does not affect either the mobility of the spine or its normal curvature.
Type III- cure with severe deformations and dysfunction of the affected organ.
Patients who have undergone a pronounced form of the process can be considered cured with bone ankylosis between the destroyed articular surfaces with the correct arrangement of bone trabeculae without signs of caseosis, or in the absence of bone ankylosis with osteosclerosis at the contacting ends of the bones and a clear pattern of the bone-trabercular network. Deformation and limitation of the function of the affected organ are consequences of the tuberculosis process and cannot serve as an obstacle to recognizing such patients as cured.
The types of cure for the osteotuberculosis process predetermine the former patient’s ability to work, the key to which is the normal or close to normal function of the affected organ, the preservation of a normal ratio of articular surfaces and the ability to support the limb.
In type III treatment, adaptive compensatory reactions are revealed in the form of arthrosis (or spondylosis), leading to severe pain and the development of contractures that sharply impair the patient’s ability to work.
In type II treatment, a pronounced deformation of the articular ends, caused by disharmony in the growth of the epiphyses under the influence of irritation of the growth zone by tuberculous toxins emanating from the primary bone lesion, can gradually, with age, significantly reduce the patient’s ability to work.
“Only early detection of osteoarticular tuberculosis and rapid elimination of primary osteitis can prevent serious consequences for normal work activity.
The achieved results are verified within 1-2 years for initial and minor forms of the process and 3-4 years for pronounced forms. If during the entire period of observation there is no active process in all other organs accessible to research, no caseosis or sequestration is detected in the lesion or in soft tissues and complete restoration of the bone lesion is noted, the patient can be considered cured.

Bone tuberculosis ranks second in prevalence among all forms of the disease, second only to pulmonary tuberculosis. The disease can occur at any age, affecting any part of the skeleton. Symptoms are often hidden and nonspecific. Treatment is carried out using conservative and surgical methods.

The essence of pathology

Tuberculosis of bones and joints is an infectious disease of the skeleton caused by mycobacteria or Koch bacilli. Any bones of the skeleton are susceptible to infection, but spongy bones are more often affected. Typically, tuberculosis of the bones is a secondary form of infection - after active pulmonary tuberculosis. The simultaneous development of these two forms of the disease is rare - in 3% of cases.

Interesting!

In 50% of cases, damage to the spine is observed. In second place is tuberculosis of the hip and knee joints.

The entry of mycobacteria into the body does not always cause the development of bone tuberculosis. For bacteria to reproduce, the following conditions are required:

• Decreased local and general immunity;
• Heavy physical activity;
• Frequent hypothermia;
• Stressful situations;
• Presence of endocrine pathology;
• Other infectious diseases;
• Bad habits.

Most often people from socially disadvantaged groups get sick. People in close, closed communities have a high risk of developing the disease - prisons, orphanages, psychiatric hospitals.

The primary focus of infection develops in the lung tissue. Then, even if the lesion becomes calcified, the mycobacterium can spread through the blood and lymphatic vessels into the bone. Where mycobacteria settle, granulomas form. As bone tissue breaks down, abscesses form. Since the blood supply to the bone is best in the area of ​​the joints, articular tuberculosis often develops.

According to ICD 10, pathology is designated by code M01.1.

Tuberculosis is treated by phthisiatricians; if necessary, they involve traumatologists, surgeons, and immunologists.

Clinical manifestations

Tuberculosis of joints and bones develops in stages:

• The first stage is called primary osteitis, where a lesion forms in the bone tissue;
• During the second stage, arthritis develops - the infection spreads to the joint;
• The third phase is residual effects. It includes relapses and complications.

Different localizations of the disease have some distinctive features:

• With spinal tuberculosis, the thoracic region is affected in 60%, and the lumbar region in 30%;
• Tuberculosis of the knee joint is typical for adolescents;
• Tuberculosis of the hip joint mainly develops in childhood and causes shortening of the limb;
• Damage to the joints of the foot leads to the formation of fistulas and ankylosis.

The disease is characterized by a long asymptomatic period. The clinical picture becomes more pronounced when the pathological process spreads beyond the bone or joint and affects the surrounding muscles. At this stage, there is a constant increase in body temperature to 37-37.5ºC. The most striking symptoms are characteristic of advanced tuberculosis with the formation of abscesses.

In children

What is tuberculosis of bones and joints in children? The disease can be suspected by changes in the child’s behavior. He becomes lethargic, absent-minded, and gets tired quickly. Children refuse their usual games. Objective symptoms in children:

• Change in posture;
• Slouch;
• Sudden limping, dragging of the leg.

If such signs appear, it is necessary to take the child to the doctor. Subsequently, there is a persistent increase in temperature to small numbers, especially in the evenings. The child's sweating increases. With further development of tuberculosis, the child complains of pain in the legs.

In adults

The first signs in adults are practically no different from those in children. The person notices increased fatigue, decreased performance, and body aches. After physical activity, pain occurs in the affected bones.

Further symptoms of tuberculosis of bones and joints are associated with the spread of infection. General malaise increases, temperature rises to 38ºС. Severe pain occurs in the affected area. With spinal tuberculosis, a change in posture is observed, the spinal muscles bulge and become tense. Damage to the joints is accompanied by an increase in their size, swelling and redness of the skin. The knee is most commonly affected. Movements in the limbs are limited and are accompanied by increased pain.

With advanced tuberculosis, the patient's condition worsens even more. There is severe weakness and a constantly high temperature. The pain becomes extremely intense. The deformation of the joints is clearly expressed, the range of motion is impaired.

In the photo, bone tuberculosis looks like various deformities of the limbs and spine.

On a note!

Tuberculosis of bones increases their fragility. Therefore, if a person begins to experience frequent fractures, he needs to be examined by a phthisiatrician.

Diagnostics

It is difficult to diagnose tuberculosis of the skeletal system. Difficulties are caused by a long asymptomatic period, the similarity of the clinical picture with other articular pathologies, and a limited number of diagnostic methods.

Tuberculin tests may be negative. The most reliable method for diagnosing tuberculosis of bones and joints is puncture of the affected bone, but this is almost impossible to do. Bone tuberculosis can be detected using the following methods:

• Chest X-ray is an indirect method that allows you to detect the primary lesion;
• X-ray of the affected bone or joint - areas of destruction, fistula tracts, bone fragments are determined;
• MRI – more accurately determines the nature of bone lesions and identifies abscesses.

Clinical blood and urine tests can reveal signs of inflammation.

Treatment methods

Treatment of tuberculosis of bones and joints is carried out in specialized anti-tuberculosis dispensaries. In the acute period, patients need bed rest and limited physical activity. Subsequently, regular stay in the fresh air, healthy eating, and giving up bad habits are required. The main treatment is carried out with anti-tuberculosis drugs; if necessary, surgery is prescribed. The duration of treatment ranges from one to three years.

Drug therapy

Mycobacterium is treated with specific anti-tuberculosis drugs:

• PASK;
• Isoniazid;
• Pyrazinamide;
• Amikacin;
• Combutol.

Today, four-component therapy is carried out. The drugs are quite toxic, affect the liver, reduce hearing, cause nausea, stool upset, and allergic reactions. To reduce side effects, vitamins, hepatoprotectors, and antihistamines are simultaneously prescribed.

It is difficult to influence the bone focus of tuberculosis with drugs. Treatment should be long-term, with regular monitoring of blood tests, ultrasound and bone x-rays.

Surgery

Indicated in cases of ineffectiveness of drug therapy and disease progression. Depending on the severity of bone destruction, three surgical techniques are used:

• Radical – the affected bone or joint is completely removed;
• Corrective – the affected area is removed, the bone is shortened;
• Reconstructive – the lesion is removed, the defect is replaced with artificial materials.

If the bone marrow is affected by Mycobacterium tuberculosis, consultation with a hematologist and immunologist is necessary before surgery.

Diet

Tuberculosis infection leads to increased loss of protein and vitamins. To replenish these substances, patients are prescribed a special diet:

• The calorie content of food increases by a third;
• The content of meat and fish in the diet increases;
• During the recovery period, increased consumption of dairy products is necessary;
• Be sure to include vegetables, fruits, and herbs in your diet.

Massage and exercise therapy

Therapeutic exercises are indicated throughout the course of the disease. It is carried out differently depending on the phase of tuberculosis:

• During the active phase, the affected limb remains motionless. The exercises are aimed at preventing muscle atrophy and joint contractures. Gymnastics uses healthy limbs;
• When the activity of the process decreases, passive exercises are performed on the affected limb. Massage is mandatory;
• During the rehabilitation period, restorative gymnastics are prescribed to regain lost self-care skills.

Gymnastics is carried out with an instructor, and then the person is given a set of exercises for independent practice.

Physiotherapy

Physiotherapy procedures are indicated during the rehabilitation period for speedy tissue restoration. The following procedures are used:

• Magnetotherapy;
• Paraffin, ozokerite applications;
• Mud baths.

Physiotherapy is carried out in courses of 10-15 procedures.

The prognosis for life with osteoarticular tuberculosis is favorable. Thanks to modern antibacterial drugs, mortality has been reduced to zero. However, more than half of the patients remain disabled.

Tuberculosis is one of the most dangerous, yet widespread infectious diseases. Most people associate this pathology with lung diseases, but Mycobacterium tuberculosis (MBT) can also affect other organs, spreading from the main source through the blood or lymphatic vessels. The second most common is tuberculosis of bones and joints, accounting for up to 5% of all tuberculosis localizations. People get this form at any age, but children suffer more often and more severely.

In addition to childhood, factors predisposing to infection and its spread to bone and joint structures are unfavorable living conditions, malnutrition, alcohol abuse, excessive physical activity and skeletal injuries.

The danger of the disease lies in the fact that the symptoms are often vague. For this reason, damage to bone and joint structures is detected already in the later stages.

All symptoms of tuberculosis can be divided into two large categories:

• are common;
• local.

The first group includes systemic manifestations of intoxication, which almost always occurs in childhood and is less common in adults. In some cases, there may be no such symptoms. The degree of their severity depends on the intensity of the tuberculosis process itself, primarily in the lungs.

Common manifestations include:

• fatigue;
• irritability;

  
  

• constant or frequently recurring low-grade fever for no apparent reason (about 37 degrees);
• poor sleep and appetite;

  
  

• reduced activity.

  
  

Local manifestations of tuberculosis of bones and joints include pain. The pain is often aching and intermittent and is not always clearly localized in the place where the inflammation process develops, but can radiate (spread).

Note! If pain localized in various skeletal structures does not go away or fades away slightly after taking painkillers, then this is a reason to immediately consult a doctor.

Local manifestations depend on the stage of the disease. As pathology develops, swelling and redness occur at the site of the affected joint. Due to increasing pain, contracture (restriction of movement) appears. Gradually, as the process progresses, deformation of the bone may occur, the tone of the surrounding muscles increases, which become painful when palpated.

Important! The symptoms indicated in the article are a reason to consult a doctor, who will make a final diagnosis and prescribe therapy. Self-diagnosis and treatment are unacceptable.

The localization of the inflammatory process also influences the characteristics of symptoms. In accordance with this parameter, there are 3 main forms of osteoarticular damage by tuberculosis:

• spondylitis - a disease of the spine;
• Osteitis – inflammation of the bones;
• arthritis is a disease of the joints.

A special type is tuberculous-allergic arthritis, which is a reaction of the articular membrane to distant localizations of the office.

Spinal tuberculosis

Tuberculous spondylitis, or Pott's disease, accounts for approximately 40% of all forms of osteoarticular tuberculosis. In the vast majority of cases, 2 vertebrae are simultaneously affected, and only in about 20% of cases is the inflammatory area wider. More often the disease affects the vertebral bodies, less often the processes.

A patient who has begun to develop spinal damage complains of weakness, fatigue and back pain, which bothers him at night. Pain syndrome is determined by light pressure on the spinous processes of the vertebrae.

As the disease develops, old symptoms intensify and new symptoms appear.

1. Gradually, a person develops an anti-pain posture, the muscles are in good shape to resist developing deformations in the vertebrae and intervertebral joints.
2. Atrophy of muscles that were previously in good shape develops.
3. Intoxication may be more obvious.
4. Due to the destruction of the vertebral bodies, a curvature of the spine is formed.
5. The patient's gait changes.
6. Movement in the affected area becomes stiff or absent altogether.
7. A common sign of progressive spondylitis in tuberculosis is cold abscessation. There are no symptoms such as pain, fever, or redness of the skin. An abscess can ultimately lead to the formation of fistulas with cheesy suppuration.

The favorite place for the development of spondylitis is the 10th vertebra (thoracic region). However, other departments may also be affected. Symptoms are determined by the localization of the inflammatory process.

Location of inflammation	Characteristic manifestations
Cervical region	The pain spreads to the back of the head and to the area above the shoulder blades. Soreness is typical when palpated. The patient avoids turning the head, and in a sitting position tries to support it under the chin with his hand. An abscess may appear as a soft, mobile swelling located on either side of the spine, sometimes extending into the space behind the pharynx.
Thoracic region	The pain radiates to the chest and abdomen. There may be tingling in the extremities. The back is under tension. To pick something up from the floor, the patient squats, trying to keep his back straight. If it is necessary to turn back, a person does not turn his body, but steps with his feet. A cold abscess appears as a soft tumor to the right or left of the spinal column. When the vertebrae are destroyed, a hump is formed.
Lumbar	The pain radiates to the legs.

A severe consequence of tuberculous spondylitis is partial or complete paralysis of the limbs, as well as disruption of the functioning of internal organs due to damage to the spinal cord and nerves.

Clinical picture of bone tuberculosis

It is with inflammation of the bone tissue (vertebral body) that the development of the infectious process in the spine usually begins. Osteitis is also considered the beginning of inflammatory phenomena in the joints.

The bone form of tuberculosis most often affects children and adolescents. Adults get sick much less often. Osteitis can affect any bone. More often, inflammation occurs in areas rich in bone marrow, for example, in the epiphyses (ends) of long bones. An extremely rare form is inflammation in the diaphysis (the middle part of the long bone containing bone marrow). The bones at the site of granuloma formation thicken. When inflammation extends beyond the bone structure, fractures are often recorded.

At the very beginning of tuberculous osteitis, pain does not bother a person, since the focus is localized in the thickness of the bone, where there are no nerve endings. Pain and other local symptoms usually appear when inflammation spreads to the periosteum, nearby joints or surrounding soft tissue. In childhood, in the first stages, the phenomenon of active growth of cartilage and bone near the joint is well expressed, which is manifested by rapid growth of the limb. The younger the child is, the more noticeable these changes are.

As with spondylitis, abscessation is characteristic, and when it breaks through to the surface of the skin, fistulas can form.

Symptoms of tuberculous joint damage

Tuberculosis most often affects large joints, which bear a large load. Among all osteoarticular forms, 20% are inflammations of the hip and knee joints.

The transition of the infectious process from bone to joint can occur in two ways, which differ in symptoms.

1. When granulation grows, the disease is not as active. This option is more typical for adults.
2. With weak immunity, for example in children, joint infection occurs when pus breaks out of the bone. This case is characterized by severe inflammation, accompanied by severe pain, high body temperature and the inability to move in the affected joint. The destruction very quickly spreads to the entire bone, causing it to thin.

In any case, the articular form is characterized by several symptoms:

• pain;
• intoxication;
• swelling around the joint;
• complete or partial immobilization;
• lameness if the leg joints are damaged;
• atrophy of surrounding tissues.

In many cases, ankylosis of the joints (fusion of articular surfaces and complete immobilization of the joint) and shortening of the limb are formed.

Features of manifestations of tuberculous-allergic arthritis

Ponce's disease is an allergic reaction of the inner articular surface to an infectious source located elsewhere. In this case, no bone changes occur.

An abscess may form. The joint is subject to deformation and ankylosis.

Due to the fact that various forms of tuberculosis of bones and joints occur for a long time with unexpressed symptoms, it is worth consulting a doctor even with mild pain and general persistent malaise. In addition, an important preventive measure is tuberculin testing or an annual chest x-ray to identify lesions in the lungs. Moreover, in Russia, unfortunately, the situation with tuberculosis remains unfavorable.

Diagnosis

Video – Tuberculosis

Bone tuberculosis is a disease that develops as a result of the active activity of tuberculous mycobacteria, which in medicine are also known as Koch bacillus. As a result of their penetration, fistulas are formed in the joint, which do not heal for a long time, its mobility is impaired, and in more severe cases it is completely destroyed. With the development and progression of spinal tuberculosis, a hump may form and the back may become curved. Without proper treatment, limb paralysis occurs.

Causes

Factors contributing to the development of pathology:

• drinking large quantities of alcoholic beverages;
• constant physical overload;
• malnutrition;
• frequent injuries of the musculoskeletal system;
• unfavorable living conditions.

Bone tuberculosis can develop both primarily and during the generalization of the infectious process in the secondary. MTB is transmitted from a sick organism to a healthy one by airborne droplets. Next, mycobacteria are transferred through the bloodstream to bone structures. A specificity gradually begins to form around them. granulomas, which, as the disease progresses, can merge and form one large conglomerate. In its center there will be a zone of cheesy necrosis. The larger the volume of affected tissue, the brighter the symptoms of tuberculosis of bones and joints.

Many are sure that if Mycobacterium tuberculosis has already penetrated the human body, then he will definitely get tuberculosis. Actually this is not true. If a person has a healthy immune system, then Koch’s bacilli are not capable of causing him any harm, since the body itself prevents the progression of pathology. Often tuberculosis of the spine or other bones and joints can resolve on its own without having any effect on the human body. But if the immune system is weakened or the person has recently suffered a serious illness, then the rods can provoke the progression of tuberculosis in any organ, spine or joints.

Phases of the disease

Bone tuberculosis occurs in 3 phases:

• prearthritic phase, also called primary osteitis;
• arthritic phase or secondary arthritis;
• post-aging phase.

Forms of pathology

There are several types of bone tuberculosis:

• Tuberculosis drives. It is this form of pathology that accounts for up to 20% of all cases of tuberculosis of bones and joints;
• spinal tuberculosis;
• omartritis;
• Tuberculous coxitis. This type of disease primarily affects children. It is dangerous because without timely treatment it can lead to deformation and dislocation of this joint;
• tuberculosis of the ankle joints and feet. The disease proceeds with the formation of long-term non-healing cavities. If it is not diagnosed in time and specific treatment is not carried out, it can progress and lead to joint immobility. This occurs because the articular surfaces fuse together;
• tuberculosis of the wrist joints. This type is rare. Its characteristic feature is bilateral damage (two joints are affected at once). The disease rarely occurs on its own; most often it is combined with pathologies of other joints;
• fawn This form of the disease predominantly affects young people;
• tuberculosis of sections of long bones. This form is extremely rare.

Symptoms

Tuberculosis of joints and bones mainly affects young children. The disease at an early stage of development is very difficult to recognize, since at this time it does not have any pronounced symptoms. Many people are sure that the symptoms of bone tuberculosis begin to appear in an adult or child after a fall or a strong blow. In fact, this statement is not true. A blow, even a very strong one, cannot provoke the progression of tuberculosis.

If you carefully monitor a child or adult, it is possible to identify the disease at an early stage of its development. It is very important to pay attention to the patient’s behavior. If this is a child, then he will refuse to play outdoor games, will be irritable, lethargic. These are the first signs that not everything is in order in the baby’s body. In addition, the child may begin to limp, stoop, raise his shoulders up, or have club feet.

In an adult, the early stage of development of the pathology is very weakly expressed. It usually manifests itself with symptoms that a person regards as normal fatigue:

• feeling of heaviness in the spine;
• fast fatiguability;
• back pain.

Symptoms of bone tuberculosis become most pronounced in phase 2 of the progression of the disease. Pain in the joints and spine intensifies. They are similar in nature to pain due to intercostal neuralgia or radiculitis. There is a limitation of mobility, the back muscles become stiff and lose their elasticity.

In the area of ​​the affected joint or spine, swelling, tissue atrophy, and accumulation of exudate are noted. The limbs shorten, the muscles become thinner and ulcers form.

Diagnostics

Tuberculosis of bones and joints is very difficult to diagnose, especially in the early stages of its development. Diagnostics includes a combination of the following studies:

• laboratory;
• clinical;
• radiographic.

The diagnostic plan in medical institutions is as follows:

• taking anamnesis;
• conducting general clinical studies;
• X-ray examination, which makes it possible to confirm the diagnosis;
• tuberculin diagnostics;
• microbiological examination of material taken during biopsy;
• rheography;
• thermography.

Treatment

Treatment of tuberculosis of the spine and other joints and bones is a very complex process.

Its main directions:

• complete destruction of the infectious agent;
• preventing bone tissue destruction;
• strengthening the patient's immune system;
• restorative treatment.

To treat this disease, doctors prescribe anti-tuberculosis chemotherapy. The selection of the scheme is carried out only by highly qualified specialists and in stationary conditions. Synthetic drugs of the first line (Pyrazinamide, Isoniazid) and second line are used.

In order to correctly draw up a treatment regimen and select the most effective drugs, the doctor must take into account the phase of development of the pathological process, the patient’s age, the presence of concomitant pathologies, the patient’s weight, etc.

Surgical treatment is indicated if drug therapy does not give the desired result, and the disease continues to progress.

The direction of such treatment is as follows:

• complete removal of the area of ​​bone destroyed by tuberculosis;
• creating the most favorable conditions for treatment;
• correction of the consequences of the disease.

Also, the treatment plan for tuberculosis of the spine and other bones and joints includes:

• physical therapy;
• orthopedic treatment;
• physiotherapy;
• abscessectomy;
• sanatorium treatment.

Bone tuberculosis is an infectious disease caused by the activity of tuberculosis microbacteria, better known as Koch bacilli. Once in the body, the infection affects the bones, which contain a spongy substance equipped with a vascular network, and causes the formation of long-term non-healing fistulas and abscesses in the joint, shortening of the limb, impaired mobility and even complete destruction of the joint. Tuberculosis of the spine leads to curvature of the back and the formation of a hump, and in some cases causes paralysis of the limbs.

Forms and phases of tuberculosis of bones and joints

There are 3 phases during the course of the disease:

1. Prearthritic phase – primary osteitis;

2. Arthritic phase – secondary arthritis, including three stages: onset, peak and subsidence;

3. Post-aging phase – exacerbation of tuberculous arthritis, its consequences, relapses and protracted course.

There are several forms of tuberculosis of bones and joints:

• Gonit – tuberculosis of the knee joints. This form of the disease accounts for about 20% of all cases of bone tuberculosis.
• Olenitis – tuberculosis of the elbow joints. Most often occurs in people under 20 years of age. The consequences of an untreated disease are fistulas and abscesses.
• Coxitis – tuberculosis of the hip joints. Most often it affects children. In advanced forms it leads to pathological dislocation or deformation of the hip joint.
• Omartritis – tuberculosis of the shoulder joints. It is a rather rare form of the disease. It is characterized by a long course without purulent effusion and exudation.
• Tuberculosis of the wrist joints. A rare form, which is characterized by a combination with pathology of other joints (elbow or knee) or bilateral damage to the bones of the wrist.
• Tuberculosis of the bones of the foot and ankle joints. It is characterized by the presence of fistulas and cavities. Often leads to complete immobilization of the joint due to the fusion of its surfaces.
• Tuberculosis of sections of long bones. The rarest form, usually starting in childhood. It affects the metacarpal bones and the main phalanges of the hand.

Causes and routes of transmission

The source of infection is the tuberculosis bacillus, which can enter the body in various ways, after which it is instantly spread through the bloodstream to all organs and tissues. Most often, infection occurs through airborne droplets through close contact with a carrier of the disease.

It is worth knowing that the entry of bacteria into the body does not always cause disease. They will not harm people with a developed and healthy immune system, since the body’s protective functions stop the onset of the disease in a timely manner. But if the immune system is weakened due to, for example, a recent illness or unfavorable living conditions, bacteria can cause the development of disease in any organ, including tuberculosis of bones and joints.

At the same time, according to statistics, adults are less susceptible to tuberculosis, since their immune system is more developed and stronger than that of children. A child’s vulnerability especially increases after influenza, measles and whooping cough. For this reason, it is extremely important to carefully monitor the condition of children after infectious diseases, and in case of the slightest suspicion, immediately contact a phthisiatrician.

In addition, the development of tuberculosis of bones and joints is facilitated by serious injuries, regular overload of the musculoskeletal system, severe hypothermia, unfavorable living and/or working conditions, and relapses of common diseases.

Symptoms of bone tuberculosis

As mentioned above, according to statistics, children are more susceptible to bone tuberculosis. It is quite difficult to recognize the disease at an early stage, because it develops without any special sensations or signs.

Many parents mistake the symptoms of bone tuberculosis for the consequences of a fall or severe bruise. This is where their mistake lies - a blow cannot provoke tuberculosis. It can develop after injury, but only if there was already a tuberculosis focus in the bone. Even a minimal pathogenic process in bones or joints after external exposure can become a “trigger” for the further development of a disease that has remained undetected until that time.

However, careful observation can detect bone tuberculosis at an early stage, so doctors strongly recommend that parents monitor the behavior of their children. Refusal from outdoor games, lethargy, irritability, fatigue, absent-mindedness - all these signs can be symptoms of tuberculosis of bones and joints. Limping, sudden stooping, clubfoot, and raised shoulders should also alert you.

Often children cannot jump on one leg; they try to step on it less, as if dragging it. Moreover, after a few hours of rest, these disturbances disappear, but recur again after some time.

Symptoms of bone tuberculosis in an adult can be: mild back pain, a feeling of heaviness in the spine, decreased performance. These signs are quite “blurry”, so not everyone pays attention to them.

The symptoms of bone tuberculosis become more pronounced in the second phase of the disease (arthritic). There is a restriction in the mobility of the joints, stiffness of movements appears (due to the fact that the muscles become inelastic and rigid).

In the area of ​​the affected joints, swelling, accumulations of serous exudate, muscle compression, and soft tissue atrophy become noticeable.

X-rays show changes in the bone: widening or narrowing of joint spaces, cavity formations in the bone, uneven surface and thinning of cartilage, lack of clear boundaries of the joints.

Also obvious symptoms of bone tuberculosis are muscle wasting, formation of ulcers, and shortening of the limbs.

Treatment of bone tuberculosis

Serious consequences can be avoided by early diagnosis and timely treatment of tuberculosis of bones and joints, although the recovery process is very long and takes at least 6 months, sometimes reaching 3 years of continuous complex treatment.

Patients with spinal tuberculosis are advised to rest in a plaster bed. This is necessary to relieve stress and ensure immobility of the spine. After the condition improves, bed rest is replaced with a plaster corset.

Effective anti-tuberculosis drugs are: Phtivazide, Rifampicin, Kanamycin, Streptomycin, Para-aminosalicylic acid. They inhibit the growth of tuberculosis microbacteria, contributing to the attenuation of the tuberculosis process, and have a beneficial effect on the general condition of a person. Antibacterial therapy with such agents is carried out for at least one year.

If necessary, the patient is offered surgical methods for the treatment of tuberculosis of bones and joints, which make it possible to completely eliminate the tuberculosis process and help restore motor abilities. This can be endoprosthetics, joint resection, alloplasty, intra-articular necrectomy and some others.