Results of conservative treatment in tuberculosis of the elbow

Current concepts in the diagnosis and management of tuberculosis of the elbow joint

Elbow is an uncommon joint to be affected by Mycobacterium tuberculosis infection. It is involved in approximately 1-5% of all cases with musculoskeletal tuberculosis (TB). Early diagnosis of TB of the elbow joint can be easily missed due to an indolent natural history, delay in presentation, and varied clinical features. Delay in diagnosis can lead to irreversible osteoarticular destruction and loss of joint function. Careful clinical assessment, adequate imaging, microbiological, and/or histopathological confirmation of Mycobacterium tuberculosis infection is essential for early diagnosis of TB of the elbow joint. Judicious and early administration of anti-tubercular therapy can lead to preservation of the joint and a satisfactory functional outcome. Surgical intervention may be needed in later stages of the disease to achieve control of the infection, correction of deformity, instability, and restoration of function.

Tuberculosis Septic Arthritis of the Elbow: A Case Report and Literature Review

Tuberculosis (TB) infections of the musculoskeletal system are rare. A 77-year-old female with chronic left elbow pain for five months was treated by irrigation and debridement of the elbow for a presumed diagnosis of septic arthritis. Her pain and wound condition did not improve, and she was referred to our institution. Plain radiograph and magnetic resonance imaging (MRI) revealed an osteolytic lesion with joint effusion and severe destruction of the elbow joint. We suspected an atypical infection of the elbow due to the chronicity, negative culture results and severe osteoarticular destruction. An open arthrotomy with irrigation and debridement was performed, and the joint was stabilized with a pin and immobilized. A tissue acid-fast bacillus (AFB) stain was positive and Mycobacterium tuberculosis culture and polymerase chain reaction (PCR) were also positive. Anti-TB drugs were started for a planned 12-month course, but she developed an adverse drug reaction from the standard regimen and had to be switched to a second-line regimen. The stitches were removed at two weeks and the wound eventually healed. The elbow was immobilized in a posterior slab for six weeks then the pin was removed. At the last follow-up visit seven months after the initial surgery, she had improved, with only mild pain on elbow motion. Her range of motion was 110 degrees of flexion and extension lag of 30 degrees.

TB of the elbow is a rare condition. The presentation is insidious and varies, and can be confused with other elbow conditions. Delayed diagnosis can lead to severe joint destruction and poor outcome. The physician should always suspect a TB elbow in cases of chronic elbow pain with synovitis, especially in areas endemic for TB. Joint fluid aspiration and MRI are the most reliable investigations for diagnosis. Anti-TB drugs are the mainstay of treatment. Appropriate surgical interventions such as drainage, synovectomy and reconstructive procedures will often be required. Collaboration between the orthopedist and an infectious specialist is essential for optimal treatment planning.

Tuberculosis of the elbow: A clinicoradiological analysis

BACKGROUND

The incidence of Tuberculosis (TB) of elbow is 2-5% of all skeletal locations. Most reports of TB elbow have focused attention on the diagnosis. The management options and classification has been missing. We present a retrospective clinicoradiological analysis of 38 cases (40 elbows) of TB of elbow joint.

MATERIALS AND METHODS

The patients presented with pain, swelling and loss of motion. Two cases had bilateral involvement. The average delay between onset of symptoms and presentation was 8 months. The elbows were classified according to modified Martini's radiological classification, which distinguishes between osseous lesions close to joint line (e.g. coronoid, condyles) and lesions away from the joint line (e.g. epicondyles, olecranon). We modified the classification to subdivide into para-articular bony lesions that had invaded the joint and those that were threatening to invade joint. All patients received antitubercular chemotherapy and immobilization in above-elbow plaster slab for 4-8 weeks. Twenty patients underwent surgical interventions (synovectomy, intraarticular debridement).

RESULTS

The average followup period was 5.3 years (range 1.5-14.2 years). The range of movement at final followup averaged 107° for stage 2, 90° for stage 3A, 47° for stage 3B and 32° for stage 4. Range of supination and pronation was less satisfactory as compared to flexion and extension and all elbows with bony involvement had less than 90° arc of supination and pronation.

CONCLUSION

Surgical intervention could appreciably alter the outcome especially in patients with extra-articular involvement close to the joint. We have classified this subgroup separately.

Two cases of chronic arthritis of the forearm due to Mycobacterium tuberculosis

In the absence of coexisting active pulmonary disease, tuberculosis is frequently not considered in the differential diagnosis of chronic inflammation of the joints. The cases of two immigrant patients with tuberculous arthritis involving the forearm are reported. In both cases non-specific arthritis or trauma was suspected, resulting in a delay between the onset of symptoms and institution of specific therapy of 21 and 24 months, respectively. Diagnosis was achieved by histological and microbiological examination of synovial biopsy material. Polymerase chain reaction for Mycobacterium tuberculosis complex was positive in only one patient. Treatment consisted of antituberculosis chemotherapy, surgical synovectomy, and debridement of the affected joints. These cases serve as a reminder that, although rare, tuberculosis can cause chronic arthritis.