Total knee arthroplasty in advanced tuberculous arthritis of the knee

The outcomes of total knee arthroplasty following the incidental finding of tuberculosis and its treatment: A prospective study

INTRODUCTION

Extrapulmonary tuberculosis (EPTB) accounts for 16 % of tuberculosis cases globally, with knee joint tuberculosis more prevalent in underdeveloped nations. Total knee arthroplasty (TKA) is commonly used to treat tubercular arthritis of knee, however, there is a marked paucity of research on the outcomes after an incidental diagnosis. The aim of the study is to investigate the outcomes of total knee arthroplasty after an incidental diagnosis of tuberculosis and its management.

METHODS

A prospective-observational study was conducted in NCR-Delhi from May 2019 to June 2023, wherein 533 patients had synovial tissue abnormalities and 11 patients reported with positive histopathological examination (HPE) for knee tuberculosis. All the patients whose informed consent was obtained were put on a twelve-month standard treatment (2HRZE or S/10HR) according to World Health Organization (WHO) guidelines for extrapulmonary TB after TKA and were monitored for the outcome of treatment, any postoperative complication, or implant failure.

RESULT

The mean age of the patients was 63 ± 13 years and 72.7 % of patients were female. The mean hemoglobin, Body Mass Index (BMI), and Erythrocyte Sedimentation Rate (ESR) values were 10.29 ± 1.36 mg/dl, 29.78 ± 6.1 kg/m2, and 37.37 mm/h respectively and the median of the C-reactive protein (CRP) value was 11 mg/dl at the time of operative procedure. All patients presented with knee-joint pain and swelling and were operated for knee-joint replacement surgery. After one year of standard treatment (2HRZE or S/10HR), no relapses, pain, or progressive radiolucency around the component, or postoperative neurologic or vascular complications were observed. The median range of motion (ROM) was improved from 10 - to 100 to 0-115, the average knee score improved from 44.9 ± 8.9 to 84.9 ± 7.73 points and the average function score improved from 28.82 ± 15.56 to 94.0 ± 7.68 points which were statistically significant at 95 % CI (p < 0.0001).

CONCLUSION

We concluded from this study that any abnormalities in ESR, CRP level prior to, and bone tissue or synovial tissue during operative procedure should be considered for articular tuberculosis and managed according to guidelines. This will make replacement procedures more sustainable and effective by lowering the risk of post-operative infection or implant-related complications and improving patients' quality of life.

A Systematic Review and Qualitative Analysis of Studies Performing Total Knee Arthroplasty (TKA) in Tuberculosis (TB) of the Knee

Tuberculosis (TB) is a widespread global disease that significantly impacts daily life. Skeletal TB comprises about 10-35% of all TB cases. Significant research on the spine and hip exists, but due to the rarity of cases, the management of TB is less explored. Furthermore, exercising the option of total knee arthroplasty (TKA) in TB knees is still in its initial stages. This systematic review aims to identify and comprehend the difficulties associated with diagnosing TB-affected knees, their treatment outcomes, and complications related to TKA. A systematic review of existing English literature retrieved from PubMed, Google Scholar, and Web of Science databases was performed using the PRISMA guidelines. A case series of arthroplasty performed on TB knees included a description of the diagnostic approach, clinical outcome, and complication rates. Moreover, studies involving case series with follow-up functional outcomes were included. The Coleman Methodology was used to assess the quality of the studies. A total of six studies (75 knees) were systematically reviewed in this study. The diagnosis of TB knee is multimodal, with MRI being a reliable tool. Administering anti-TB chemotherapy is essential during the perioperative period. Regarding recurrence, a two-stage TKA has a lower risk of recurrence. It is plausible to state that anti-TB chemotherapy needs to be initiated in the perioperative period to prevent the chances of recurrences. Two-stage TKA is reserved for patients who require soft tissue debridement despite adequate chemotherapy.

Tuberculous arthritis of native joints - a systematic review and European Bone and Joint Infection Society workgroup report

Introduction: The aim of this systematic review was to assess the existing published data on the diagnosis and management of tuberculosis (TB) arthritis involving native joints in adults aged 18 years and older. Methods: This study was performed in accordance with the guidelines provided in the Preferred Reporting Items for Systematic reviews and Meta-Analysis extension for Scoping Reviews (PRISMA-ScR). Results: The systematic review of the literature yielded 20 data sources involving 573 patients from nine countries. There was considerable variation amongst the studies in terms of the approach to diagnosis and management. The diagnosis was mostly made by microbiological tissue culture. Medical management involved a median of 12 months of anti-tubercular treatment (interquartile range, IQR, of 8-16; range of 4-18 months). The duration of preoperative treatment ranged from 2 to 12 weeks. Surgery was performed on 87 % of patients and varied from arthroscopic debridement to complete synovectomies combined with total joint arthroplasty. The mean follow-up time of all studies was 26 months (range of 3-112 months). Recurrence rates were reported in most studies, with an overall average recurrence rate of approximately 7.4 % (35 of 475 cases). Conclusions: The current literature on TB arthritis highlights the need for the establishment of standardized guidelines for the confirmation of the diagnosis. Further research is needed to define the optimal approach to medical and surgical treatment. The role of early debridement in active TB arthritis needs to be explored further. Specifically, comparative studies are required to address questions around the use of medical treatment alone vs. in combination with surgical intervention.

Two-stage TKA for tuberculosis septic arthritis of the knee masquerading as pigmented villonodular synovitis: A case report

A 25-year-old female presented with left knee pain following arthroscopic synovectomy for presumed pigmented villonodular synovitis (PVNS). Radiographs and magnetic resonance imaging demonstrated tricompartmental arthritic changes. She underwent a two-stage procedure first involving antibiotic spacer implantation, followed 1 week later by spacer removal and definitive total knee arthroplasty (TKA) once initial intraoperative culture results were negative. Subsequent cultures confirmed tuberculosis septic arthritis. Repeat evaluation 1 year postoperatively showed no complications and patient satisfaction with left knee function. This is a unique case report in the United States describing 1-year outcomes following staged TKA for tuberculosis septic arthritis masquerading as PVNS.

Total Knee Arthroplasty in Patients with Unsuspected Tuberculosis of the Joint: A Report of Four Cases and a Systematic Review of the Literature

OBJECTIVES

To provide a case series and systematic review that explores the clinical manifestations, treatments, and methods for defining tuberculosis diagnoses in patients who have undergone total knee arthroplasty (TKA).

METHODS

Four patients (three women, one man; average age, 59.5 ± 8.89 years; range, 48-69 years) underwent TKA and were subsequently treated for previously unsuspected knee tuberculosis between January 2013 and December 2019. We also reviewed published cases of tuberculous periprosthetic joint infections (TBPJIs) following TKA through databases of MEDLINE/PubMed, the Cochrane Library, and EMBASE. We reviewed studies that were published between January 1980 and December 2019.

RESULTS

In our four cases, the preoperative diagnoses were osteoarthritis (n = 2), rheumatoid arthritis (one case), and Charcot's arthropathy (one case). The main clinical manifestations were knee swelling and pain, without fever, weakness, or weight loss. Comorbidities included multiple joints with rheumatoid arthritis or Charcot's arthropathy, diabetes mellitus, and uremia. One patient had a history of lumbar tuberculosis treated with debridement and intervertebral fusion. Preoperative elevated erythrocyte sedimentation rates (ESRs) were detected in all cases, and elevated C-reactive protein (CRP) levels were observed in three cases. The tuberculosis diagnoses were confirmed via histopathologic analysis (three cases) and second-generation sequencing (one case). Three patients received antituberculosis therapy for 1 year, without surgical intervention. Two-stage exchange arthroplasty was performed in one patient because of prosthesis loosening. Within an average follow-up period of 24.75 months, tuberculosis reactivation was not observed and overall functional improvement was demonstrated. Forty-four TBPJI cases were reported in the literature between January 1980 and December 2019. Most (59.09%) occurred within the first year after the index arthroplasty, and the diagnoses were confirmed by culturing Mycobacterium tuberculosis in 88.64% of cases. Favorable outcomes were achieved in 90.91% of the patients who did not undergo surgery, 71.43% of those treated with debridement, 93.33% undergoing revision arthroplasty, and in 90.91% of those undergoing resection and arthrodesis.

CONCLUSIONS

Clinical manifestations of knee tuberculosis and TBPJI are atypical. Thus, attention should be paid to finding the causes of increased ESRs and CRP levels, particularly in patients with weakened immune functioning, before performing TKA. Pathological examination is an effective method for diagnosing tuberculosis, although sending multiple specimens for pathological examination is necessary.

Tuberculosis of the knee: A pitfalls in clinical settings (A case report and literature review)

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We herein present a case of an unusual manifestation of knee tuberculosis. Its slowly progressive disease characteristics after being ignored for 5 years interest the authors to report this case report. Without doing arthoplasty, synovectomy followed by 1 year of anti-tuberculosis treatment give positive improvement of the patient where he can continue his job and daily activities as before he got the disease 5 years ago. Slight deformity resulted in muscle stiffness may be restorated after few months of physical rehabilitation.

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Further monitoring is needed anually for assessing the long term complications of knee tuberculosis, including early secondary osteoarthritis.

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The place of conducting the case report in Indonesia, mainly in Sumatera Utara. Thus, we hope that the manuscript fits the scope of International journal for Surgery Case Report. The article is original, unpublished, and not being considered for publication elsewhere.

Introduction

Tuberculosis of the knee is a rare form of diseases associated with tuberculosis that is frequently misdiagnosed as malignancy or bacterial infections. Its symptomatology might be identical to other conditions; thus finally turns the clinician misdiagnosed of the patient circumstances.

Presentation of the case

A 31-year-old male patient presented a unilateral knee swelling, reddish, warmth, pain, with a limited range of movement and then diagnosed with tuberculosis of the knee, histopathologically confirmed following surgical removal, including synovectomy without arthroplasty procedure. Furthermore, the patients underwent the administration of an anti-tuberculous drug regiment for a 1-year period. There was clinical improvement attained afterward after the prompt management since the initiation of therapy progressively.

Discussion

This case is unique due to the unspecific clinical manifestations of the disease, which contributed to delay diagnosis. Further, either the patients and his parents still had a lack of knowledge according to his condition. Opposite to the recent studies, there was an excellent outcome after simple surgical procedure, including synovectomy without arthroplasty followed by 1 year of anti-tuberculous drug.

Conclusion

Knee tuberculosis is a rare disease that often misdiagnosed as bacterial infections or malignancy. Mimicking clinical manifestations needs further surgical approach followed by histopathology examination to diagnose this disease. Early recognition and prompt treatment were crucially required to avoid the permanent limitation of movement that could affect the patient’s quality of life. In this case, a lack of knowledge of the patient and his family significantly contributes to the delayed diagnosis.