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Tuberculous bone and joint infection
Treatment-(b) Infection
Tuberculous Bone and Joint
John C. Leong
Introduction
any part of the spine. It may involve multiple levels and kyphosis, sometimes with a bayonet deformity, is a frequent complication. In a typical case, the patient presents with malaise, pain, and a gibbus. ‘Asthma milare’ may occur when an abscess in the upper dorsal spine causes pressure on the bronchi, especially in the supine position at night. Paralysis may complicate both active and healed disease especially if it involves the cervial spine in children.? Radiographic findings include a paravertebral abscess on the AP view, narrowing of one or more disc spaces with erosion of the vertebral body above and below. In the lumbar spine, a paravertebral abscess shadow is uncommon, as pus tends to track along the psoas sheath. In children, an abscess in the thoracic spine tends to strip up the ligaments and periosteum of the adjacent vertebrae, disturbing the blood supply to the anterior part. This avascular area is rapidly eroded by the pulsative movements of the adjacent aorta, leaving a scalloped appearance, described as an aneurysmal syndrome. The controversy whether tuberculosis of the spine can and should be treated by chemotherapy alone, or chemotherapy with surgical intervention, was triggered off in the late 1950s and early 1960s by Studies from Nigeria and Hong Kong.34 In the former, patients were treated entirely on chemotherapy alone, whereas in the latter surgical intervention in the presence of chemotherapy was advocated. The rationale of surgical treatment is based on the following:5 1) The patient’s general condition improves dramatically immediately after evacuation of the abscess. 2) Avascular material may be removed, and the insertion of an anterior strut graft under compression will lead to early fusion. 3) Late recurrence is uncommon (after radical excision of the disease
Tuberculosis of bone and joint remains a disease which is prevalent in many parts of the world. Even in the so-called developed countries, it ‘is not a disease of bygone years’. l In a retrospective study, from one medical centre in Pennsylvania, 24 patients with musculo-skeletal tuberculosis of recent onset were found in a lo-year period. Interestingly, the patients came from a rural middle-class population and because of the general unawareness of the condition, the average delay in diagnosis was 19 weeks with a maximum of 2 years. An analysis of 2000 consecutive cases of tuberculosis of bone and joint in Hong Kong from 1957-1961 showed the spine to be most commonly involved, followed by the hip, and then the knee. Although the overall incidence of such disease has dropped markedly to approximately 20 cases per year, the distribution remains the same. The most commonly employed first line drugs include a combination of streptomycin, isoniazid, and rifampicin. In truly resistant cases, which are uncommon, second line drugs are necessary, although the latter are more toxic and have more sideeffects.
Tuberculosis of the Spine Although the incidence used to be highest in children, it is now more common in adults owing to the introduction of the BCG vaccination at birth and to the improvement in socio-economic conditions in the community. The thoraco-lumbar region is most commonly involved, although the disease can be found in John C. Leong FRCS, FRCSE, FRAYS, Professor and Head, Department of Orthopaedic Surgery, University of Hong Kong at Queen Mary Hospital, Hong Kong. Current Orlhopaedics 0 1988 Longman
(1988) 2.86-89
Group
UK Ltd
86
CURRENT
focus and solid fusion has been achieved.) 4) Disease material may be obtained for a definitive diagnosis. 5) Increasing deformity can be prevented. 6) Paraplegia can be prevented, or if established, anterior decompression with bone grafting leads to rapid recovery. In an attempt to address such controversy the Medical Research Council of Britain started a series of trials comparing, a) chemotherapy with immobilisation in bed or in a plaster cast, b) chemotherapy with ambulant patients, c) limited debridement and, d) radical excision of the lesion followed by anterior spinal fusion. The results are contained in several reports, commencing in 19736 and culminating in the 8th and 9th reports in 1982’ and 19858 respectively. These trials by an independent institution showed that tuberculosis of the spine can be treated successfully by conservative as well as surgical methods. However, results demonstrated that radical excision of the diseased focus together with anterior spinal fusion has definite advantages. These include 1) early bony fusion, 2) vertebral reconstitution, 3) no increase in kyphosis, 4) complete healing of sinuses or abscesses 18 months after the start of treatment, and 5) no occurrence of neurologic involvement after the start of the treatment regime. In patients with impending or established paraplegia, anterior decompression is mandatory, as it leads to rapid return of spinal cord function.” Experience in our centre showed that some patients who have had a supervised regime of chemotherapy in their early adulthood may present again 30-40 years later with slowly progressive deformity, impending paraplegia and re-activation of the disease. In such patients the bone is osteoporotic and the age of the patient does not permit prolonged recumbancy, whilst on the other hand surgical intervention with fusion and instrumentation are extremely difficult.
ORTHOPAEDICS
87
One of the sequelae of tuberculosis of the spine is a severe, angular, and rigid kyphosis. Apart from marked reduction in cardiopulmonary function and a cosmetic problem, there may also be spontaneous onset of paraplegia. Correction of such deformities is possible, but requires multiple major operative procedures including: a) a halo-pelvic apparatus application, b) anterior spinal osteotomy, c) posterior spinal osteotomy, and fusion, d) traction to achieve correction over 4-6 weeks, e) finally an anterior strut fusion (Figs 1 & 2). The initial management of tuberculosis of the spine should aim at preventing these deformities in the short or long term.
Tuberculosis Of The Hip The highest incidence is found between the ages of 1 and 17 years. I@Patients may present in childhood with the acute disease or in later life with longstanding disease, often with marked destruction of the joint. Awareness of the condition is vital to the diagnosis as even in fresh cases the onset is insidious, and X-ray changes always lag far behind the pathological stage of the disease. With florid synovitis and joint effusion, the joint space at first widens. Two to four months after the onset, most cases show widespread osteoporosis in the hip region. Sometimes a typical area of rarefaction may be found in the acetabular roof or in Babcock’s triangle. Lateronsequestra, furthererosion, cavitation, narrowing of the joint space and more advanced destruction may occur. The aim of treatment at the early stage is to eradicate the disease and obtain as normal a joint as possible. Chemotherapy for an adequate period (usually 9 months) is essential. If the response is not favourable within a short period of time, arthrotomy is indicated. The latter provides early decompression, proof of the disease by biopsy and isolation of the organism,
88
TREATMENT-(B)
TUBERCULOUS
Fig. 2-(A) Pre-operative clinical appearance. operative clinical appearance.
BONE AND
JOINT INFECTION
(6) Post-
removal of diseased and necrotic tissues which delay healing, prevention of further damage to articular cartilage by tuberculous granulation tissue, and visualisation of the condition of the joint which enables one to decide whether a useful range of motion can be preserved or arthorodesis is necessary. Post-operatively, if useful function is anticipated, traction is continued for at least 3 weeks, and a further period of 3 weeks of plaster immobilisation is required. Thereafter mobilisation is started and increasing weight bearing allowed. If the articular cartilage is so destroyed that useful movement is not possible, arthrodesis may be indicated. However, before such a formal procedure is done, immobilisation in plaster in an optimal position for a total of 3 months may result in a firm fibrous union without pain or a restricted degree of painless motion. In these cases, the decision to perform arthrodesis should be delayed. In patients with long-standing disease, and frequently with significant destruction of the joint, treatment is more controversial. Such patients are usually in their adulthood. The ideal would be a painless, mobile, and stable hip. If all these cannot be achieved, freedom from pain is the primary concern, and patients will have to be satisfied with either a mobile but relatively unstable hip, or a stable but stiff hip. To attain or preserve mobility, there are three possibilites a) excision arthroplasty, b) amniotic arthroplasty, and c) replacement arthroplasty. Girdlestone’s excision arthroplasty is an established procedure, but results in a joint which is relatively unstable, and with significant leg shortening. A recent study’ l in 30 patients showed marked or complete relief of pain in 29, squatting and sitting cross-legged was possible in 27, and 16 were able to stand on the operated limb. A multi-layered amniotic cap may be interposed in a degenerate joint. A cleft forms in the plane of
movement after 2 months and synovial-like tissue lines the wall of the cleft. In a series of 28 patients with tuberculous arthritis treated by amniotic arthroplasty, no obvious rejection phenomenon was observed, and 25 patients were free of symptoms with only an average of 0.5 cm extra shortening.‘? The joints were mobile (22 could squat, 24 could sit crosslegged), and stable. Although the follow-up was short (range from 30-46 months) this work opens up a new avenue for surgical treatment and warrants further research. Total hip replacement for quiescent tuberculous hips has been reported. ’ 3 Although results are encouraging with few complications, reactivation of infection is always possible and has been reported.14J5 The procedure can present technical difficulties, and should not be undertaken lightly. The most permanent solution to a destroyed tuberculous hip is a solid bony fusion. An intra-articular or an extra-articular arthrodesis are both possible although with the usual gross destruction of the head and neck, an extra-articular fusion as described by Britain is the preferred method (Fig. 3). Our centre has reported 44 children treated by this method with a fusion rate of almost 90%. I6 There remains of course the long-term problem of increased stress in the lumbar spine and the ipsilateral knee.
Tuberculosis of the Knee The peak incidence varies with different reports.17,18 In our centre, 75% of patients had the disease before the age of 18, with a peak at the age of 4 years. Others have reported a preponderance of adult patients. Patients may present in the synovitis stage of the disease, or when there is already obvious bony involvement or joint destruction. Controversy exists as to whether conservative treatment with chemotherapy and with immobilisation for a short period (less than 1 month), or synovectomy followed by similar period of rest is the preferred method of treatment. Good results in the early, mainly synovial stage of the disease have been reported. la Synovectomy and immobilisation is likely to produce a pain-free relatively stiff knee. Conservative treatment is likely to result in a greater range of movement but with an increased likelihood of discomfort. l 7 It is noteworthy that the results are significantly better in young patients and when treatment has been started in the early stages of the disease. When children are involved, the power of reconstitution of the joint is remarkable. The soft bone surfaces adapt to each other giving rise to ‘congruous incongruity’. Pain is not a prominent feature in most of these patients, even after 15-20 years of follow-up. Other surgical procedures used for the treatment of tuberculosis of the knee include arthrodesis and supracondylar osteotomy. A relatively stiff knee with a fibrous union does not warrant a formal arthrodesis (Fig. 4) unless there is significant pain or deformity. Supracondylar osteotomy is useful in cases with residual flexion contracture.
CURRENT
Fig. 3-(A) Tuberculosis of the left hip in a lo-year-old patient. There is chronic dislocation ye&s after f3ritain’s extra-articular arthrodesis showing a-solid fusion.
89
ORTHOPAEDICS
and an upward riding femur. (B) Nine
Riseborough E J (eds) Controversies W B Saunders Company 472486.
in Orthopaedic
Surgery.
6. Medical Research Council Working Party on Tuberculosis of the spine (First Report) 1973 A controlled trial of ambulant out-patient treatment and in-patient rest in bed in the management of tuberculosis of the spine in young Korean patients on standard chemotherapy. A Study in Masan. Korea. Journal of Bone and Joint Surgery 55B: 6788697 7. Medical Research Council Working Party on Tubercuiosis of the Spine (Eight Report) 1982 A lo-Year assessment of a controlled trial comparing debridement and anterior spinal fusion in the management of tuberculosis of the spine in patients on standard chemotherapy in Hong Kong. Journal of Bone and Joint Surgery 64B: 393-398. 8. Medical Research Council Working Party on Tuberculosis of the Spine (Ninth Report) 1985. A lo-Year assessment of controlled trials of in-patient and out-patient treatment and of plaster-of-Paris jackets for tuberculosis of the spine in children on standard chemotherapy. Studies in Masan and Pusan, Korea. Journal of Bone and Joint Surgery 67B: 103 110. 9. Hodgson A R, Yau A C M C, Kwon J S, Kim D 1964 A Clinical Study of 100 Consecutive cases of Pott‘s paraplegia. Clinical Orthopaedics 36: 128-l 50 10. Hodgson A R. Fang David 1981 Tuberculosisof the hip in children. Hip disorders in infants and children. Lea & Febiger Chapter 1 IC: 221-233.
Fig. &Long-standing tuberculosis of the knee showing fibro IUSankylosis. There was only 5-10” of knee movemer It, but little deformity and no pain.
Rel‘erences I. Wolfgang G L 1978 Tuberculosis joint infection. Clinical Orthopaedics 136: 257-263 2. Hsu L C S. Leong J C Y 1984 Tuberculosis of the lower cervical spine (C2 to C7). Journal of Bone and Joint Surgery 66B: I-5 3. Konstam P G, Blesovsky A 1962 The Ambulant treatment of spinal tuberculosis. British Journal of Surgery 50: 2638 4. Hodgson A R, Stock F E 1960 Anterior spine fusion for the treatment of tuberculosis of the spine Journal of Bone and Joint Surgery 42A: 295-310 5. Leong J C Y, Hodgson A R 1982 Surgical treatment of tuberculosis of the spine. In: Leach R E, Hoaglund F T.
11. Tuli S M, Mukherjee S K 1981 Excision Arthroplasty for tuberculous and pyogenic arthritis of the hip. Journal of Bone and Joint Surgery 63B : 29-32. 12. Vishwakarma G K, Khare A K 1986 Amniotic arthroplastyfor tuberculosis of the hip A preliminary clinical study. Journal of Bone and Joint Surgery 68B : 68-74 13. Kim Y Y. Ahn B H, Bae D K, Ko C U, Lee J D, Kwak B M, Yoon Y S 1986 Arthroplasty using the Charnley prosthesis in old tuberculosis of the hip Clinical experience with 8-10 year follow-up evaluation. Clinical Orthopaedics 2 1 I : 1 I& 121, 14. Johnson R, Barnes K L, Owen R 1979 Reactivation of tuberculosis after total hip replacement. Journal of Bone and JointSurgery61B: 148-150 15. Hecht R H, Meyers M H, Thomhill-Joynes M. Montgomerie J Z 1983 Reactivation of tuberculous infection following total joint replacement A case report. Journal of Bone and Joint Surgery65A: 1015-1016 16. Chan K P, Shin J S 1968 Brittain’s ischiofemoral arthrodesis for tuberculosis of the hip. Journal of Bone & Joint Surgery 50A: 1341 17. Chow S P, Yau A 1980 Tuberculosis of the knee--A long term follow-up. International Orthopaedics 4: 87-92 18. Wilkinson M C 1969 Tuberculosis of the hip and knee treated by chemotherapy, synovectomy and debridement. Journal of Bone and Joint Surgery 51A: 134331359
Tuberculous Bone and Joint
John C. Leong
Introduction
any part of the spine. It may involve multiple levels and kyphosis, sometimes with a bayonet deformity, is a frequent complication. In a typical case, the patient presents with malaise, pain, and a gibbus. ‘Asthma milare’ may occur when an abscess in the upper dorsal spine causes pressure on the bronchi, especially in the supine position at night. Paralysis may complicate both active and healed disease especially if it involves the cervial spine in children.? Radiographic findings include a paravertebral abscess on the AP view, narrowing of one or more disc spaces with erosion of the vertebral body above and below. In the lumbar spine, a paravertebral abscess shadow is uncommon, as pus tends to track along the psoas sheath. In children, an abscess in the thoracic spine tends to strip up the ligaments and periosteum of the adjacent vertebrae, disturbing the blood supply to the anterior part. This avascular area is rapidly eroded by the pulsative movements of the adjacent aorta, leaving a scalloped appearance, described as an aneurysmal syndrome. The controversy whether tuberculosis of the spine can and should be treated by chemotherapy alone, or chemotherapy with surgical intervention, was triggered off in the late 1950s and early 1960s by Studies from Nigeria and Hong Kong.34 In the former, patients were treated entirely on chemotherapy alone, whereas in the latter surgical intervention in the presence of chemotherapy was advocated. The rationale of surgical treatment is based on the following:5 1) The patient’s general condition improves dramatically immediately after evacuation of the abscess. 2) Avascular material may be removed, and the insertion of an anterior strut graft under compression will lead to early fusion. 3) Late recurrence is uncommon (after radical excision of the disease
Tuberculosis of bone and joint remains a disease which is prevalent in many parts of the world. Even in the so-called developed countries, it ‘is not a disease of bygone years’. l In a retrospective study, from one medical centre in Pennsylvania, 24 patients with musculo-skeletal tuberculosis of recent onset were found in a lo-year period. Interestingly, the patients came from a rural middle-class population and because of the general unawareness of the condition, the average delay in diagnosis was 19 weeks with a maximum of 2 years. An analysis of 2000 consecutive cases of tuberculosis of bone and joint in Hong Kong from 1957-1961 showed the spine to be most commonly involved, followed by the hip, and then the knee. Although the overall incidence of such disease has dropped markedly to approximately 20 cases per year, the distribution remains the same. The most commonly employed first line drugs include a combination of streptomycin, isoniazid, and rifampicin. In truly resistant cases, which are uncommon, second line drugs are necessary, although the latter are more toxic and have more sideeffects.
Tuberculosis of the Spine Although the incidence used to be highest in children, it is now more common in adults owing to the introduction of the BCG vaccination at birth and to the improvement in socio-economic conditions in the community. The thoraco-lumbar region is most commonly involved, although the disease can be found in John C. Leong FRCS, FRCSE, FRAYS, Professor and Head, Department of Orthopaedic Surgery, University of Hong Kong at Queen Mary Hospital, Hong Kong. Current Orlhopaedics 0 1988 Longman
(1988) 2.86-89
Group
UK Ltd
86
CURRENT
focus and solid fusion has been achieved.) 4) Disease material may be obtained for a definitive diagnosis. 5) Increasing deformity can be prevented. 6) Paraplegia can be prevented, or if established, anterior decompression with bone grafting leads to rapid recovery. In an attempt to address such controversy the Medical Research Council of Britain started a series of trials comparing, a) chemotherapy with immobilisation in bed or in a plaster cast, b) chemotherapy with ambulant patients, c) limited debridement and, d) radical excision of the lesion followed by anterior spinal fusion. The results are contained in several reports, commencing in 19736 and culminating in the 8th and 9th reports in 1982’ and 19858 respectively. These trials by an independent institution showed that tuberculosis of the spine can be treated successfully by conservative as well as surgical methods. However, results demonstrated that radical excision of the diseased focus together with anterior spinal fusion has definite advantages. These include 1) early bony fusion, 2) vertebral reconstitution, 3) no increase in kyphosis, 4) complete healing of sinuses or abscesses 18 months after the start of treatment, and 5) no occurrence of neurologic involvement after the start of the treatment regime. In patients with impending or established paraplegia, anterior decompression is mandatory, as it leads to rapid return of spinal cord function.” Experience in our centre showed that some patients who have had a supervised regime of chemotherapy in their early adulthood may present again 30-40 years later with slowly progressive deformity, impending paraplegia and re-activation of the disease. In such patients the bone is osteoporotic and the age of the patient does not permit prolonged recumbancy, whilst on the other hand surgical intervention with fusion and instrumentation are extremely difficult.
ORTHOPAEDICS
87
One of the sequelae of tuberculosis of the spine is a severe, angular, and rigid kyphosis. Apart from marked reduction in cardiopulmonary function and a cosmetic problem, there may also be spontaneous onset of paraplegia. Correction of such deformities is possible, but requires multiple major operative procedures including: a) a halo-pelvic apparatus application, b) anterior spinal osteotomy, c) posterior spinal osteotomy, and fusion, d) traction to achieve correction over 4-6 weeks, e) finally an anterior strut fusion (Figs 1 & 2). The initial management of tuberculosis of the spine should aim at preventing these deformities in the short or long term.
Tuberculosis Of The Hip The highest incidence is found between the ages of 1 and 17 years. I@Patients may present in childhood with the acute disease or in later life with longstanding disease, often with marked destruction of the joint. Awareness of the condition is vital to the diagnosis as even in fresh cases the onset is insidious, and X-ray changes always lag far behind the pathological stage of the disease. With florid synovitis and joint effusion, the joint space at first widens. Two to four months after the onset, most cases show widespread osteoporosis in the hip region. Sometimes a typical area of rarefaction may be found in the acetabular roof or in Babcock’s triangle. Lateronsequestra, furthererosion, cavitation, narrowing of the joint space and more advanced destruction may occur. The aim of treatment at the early stage is to eradicate the disease and obtain as normal a joint as possible. Chemotherapy for an adequate period (usually 9 months) is essential. If the response is not favourable within a short period of time, arthrotomy is indicated. The latter provides early decompression, proof of the disease by biopsy and isolation of the organism,
88
TREATMENT-(B)
TUBERCULOUS
Fig. 2-(A) Pre-operative clinical appearance. operative clinical appearance.
BONE AND
JOINT INFECTION
(6) Post-
removal of diseased and necrotic tissues which delay healing, prevention of further damage to articular cartilage by tuberculous granulation tissue, and visualisation of the condition of the joint which enables one to decide whether a useful range of motion can be preserved or arthorodesis is necessary. Post-operatively, if useful function is anticipated, traction is continued for at least 3 weeks, and a further period of 3 weeks of plaster immobilisation is required. Thereafter mobilisation is started and increasing weight bearing allowed. If the articular cartilage is so destroyed that useful movement is not possible, arthrodesis may be indicated. However, before such a formal procedure is done, immobilisation in plaster in an optimal position for a total of 3 months may result in a firm fibrous union without pain or a restricted degree of painless motion. In these cases, the decision to perform arthrodesis should be delayed. In patients with long-standing disease, and frequently with significant destruction of the joint, treatment is more controversial. Such patients are usually in their adulthood. The ideal would be a painless, mobile, and stable hip. If all these cannot be achieved, freedom from pain is the primary concern, and patients will have to be satisfied with either a mobile but relatively unstable hip, or a stable but stiff hip. To attain or preserve mobility, there are three possibilites a) excision arthroplasty, b) amniotic arthroplasty, and c) replacement arthroplasty. Girdlestone’s excision arthroplasty is an established procedure, but results in a joint which is relatively unstable, and with significant leg shortening. A recent study’ l in 30 patients showed marked or complete relief of pain in 29, squatting and sitting cross-legged was possible in 27, and 16 were able to stand on the operated limb. A multi-layered amniotic cap may be interposed in a degenerate joint. A cleft forms in the plane of
movement after 2 months and synovial-like tissue lines the wall of the cleft. In a series of 28 patients with tuberculous arthritis treated by amniotic arthroplasty, no obvious rejection phenomenon was observed, and 25 patients were free of symptoms with only an average of 0.5 cm extra shortening.‘? The joints were mobile (22 could squat, 24 could sit crosslegged), and stable. Although the follow-up was short (range from 30-46 months) this work opens up a new avenue for surgical treatment and warrants further research. Total hip replacement for quiescent tuberculous hips has been reported. ’ 3 Although results are encouraging with few complications, reactivation of infection is always possible and has been reported.14J5 The procedure can present technical difficulties, and should not be undertaken lightly. The most permanent solution to a destroyed tuberculous hip is a solid bony fusion. An intra-articular or an extra-articular arthrodesis are both possible although with the usual gross destruction of the head and neck, an extra-articular fusion as described by Britain is the preferred method (Fig. 3). Our centre has reported 44 children treated by this method with a fusion rate of almost 90%. I6 There remains of course the long-term problem of increased stress in the lumbar spine and the ipsilateral knee.
Tuberculosis of the Knee The peak incidence varies with different reports.17,18 In our centre, 75% of patients had the disease before the age of 18, with a peak at the age of 4 years. Others have reported a preponderance of adult patients. Patients may present in the synovitis stage of the disease, or when there is already obvious bony involvement or joint destruction. Controversy exists as to whether conservative treatment with chemotherapy and with immobilisation for a short period (less than 1 month), or synovectomy followed by similar period of rest is the preferred method of treatment. Good results in the early, mainly synovial stage of the disease have been reported. la Synovectomy and immobilisation is likely to produce a pain-free relatively stiff knee. Conservative treatment is likely to result in a greater range of movement but with an increased likelihood of discomfort. l 7 It is noteworthy that the results are significantly better in young patients and when treatment has been started in the early stages of the disease. When children are involved, the power of reconstitution of the joint is remarkable. The soft bone surfaces adapt to each other giving rise to ‘congruous incongruity’. Pain is not a prominent feature in most of these patients, even after 15-20 years of follow-up. Other surgical procedures used for the treatment of tuberculosis of the knee include arthrodesis and supracondylar osteotomy. A relatively stiff knee with a fibrous union does not warrant a formal arthrodesis (Fig. 4) unless there is significant pain or deformity. Supracondylar osteotomy is useful in cases with residual flexion contracture.
CURRENT
Fig. 3-(A) Tuberculosis of the left hip in a lo-year-old patient. There is chronic dislocation ye&s after f3ritain’s extra-articular arthrodesis showing a-solid fusion.
89
ORTHOPAEDICS
and an upward riding femur. (B) Nine
Riseborough E J (eds) Controversies W B Saunders Company 472486.
in Orthopaedic
Surgery.
6. Medical Research Council Working Party on Tuberculosis of the spine (First Report) 1973 A controlled trial of ambulant out-patient treatment and in-patient rest in bed in the management of tuberculosis of the spine in young Korean patients on standard chemotherapy. A Study in Masan. Korea. Journal of Bone and Joint Surgery 55B: 6788697 7. Medical Research Council Working Party on Tubercuiosis of the Spine (Eight Report) 1982 A lo-Year assessment of a controlled trial comparing debridement and anterior spinal fusion in the management of tuberculosis of the spine in patients on standard chemotherapy in Hong Kong. Journal of Bone and Joint Surgery 64B: 393-398. 8. Medical Research Council Working Party on Tuberculosis of the Spine (Ninth Report) 1985. A lo-Year assessment of controlled trials of in-patient and out-patient treatment and of plaster-of-Paris jackets for tuberculosis of the spine in children on standard chemotherapy. Studies in Masan and Pusan, Korea. Journal of Bone and Joint Surgery 67B: 103 110. 9. Hodgson A R, Yau A C M C, Kwon J S, Kim D 1964 A Clinical Study of 100 Consecutive cases of Pott‘s paraplegia. Clinical Orthopaedics 36: 128-l 50 10. Hodgson A R. Fang David 1981 Tuberculosisof the hip in children. Hip disorders in infants and children. Lea & Febiger Chapter 1 IC: 221-233.
Fig. &Long-standing tuberculosis of the knee showing fibro IUSankylosis. There was only 5-10” of knee movemer It, but little deformity and no pain.
Rel‘erences I. Wolfgang G L 1978 Tuberculosis joint infection. Clinical Orthopaedics 136: 257-263 2. Hsu L C S. Leong J C Y 1984 Tuberculosis of the lower cervical spine (C2 to C7). Journal of Bone and Joint Surgery 66B: I-5 3. Konstam P G, Blesovsky A 1962 The Ambulant treatment of spinal tuberculosis. British Journal of Surgery 50: 2638 4. Hodgson A R, Stock F E 1960 Anterior spine fusion for the treatment of tuberculosis of the spine Journal of Bone and Joint Surgery 42A: 295-310 5. Leong J C Y, Hodgson A R 1982 Surgical treatment of tuberculosis of the spine. In: Leach R E, Hoaglund F T.
11. Tuli S M, Mukherjee S K 1981 Excision Arthroplasty for tuberculous and pyogenic arthritis of the hip. Journal of Bone and Joint Surgery 63B : 29-32. 12. Vishwakarma G K, Khare A K 1986 Amniotic arthroplastyfor tuberculosis of the hip A preliminary clinical study. Journal of Bone and Joint Surgery 68B : 68-74 13. Kim Y Y. Ahn B H, Bae D K, Ko C U, Lee J D, Kwak B M, Yoon Y S 1986 Arthroplasty using the Charnley prosthesis in old tuberculosis of the hip Clinical experience with 8-10 year follow-up evaluation. Clinical Orthopaedics 2 1 I : 1 I& 121, 14. Johnson R, Barnes K L, Owen R 1979 Reactivation of tuberculosis after total hip replacement. Journal of Bone and JointSurgery61B: 148-150 15. Hecht R H, Meyers M H, Thomhill-Joynes M. Montgomerie J Z 1983 Reactivation of tuberculous infection following total joint replacement A case report. Journal of Bone and Joint Surgery65A: 1015-1016 16. Chan K P, Shin J S 1968 Brittain’s ischiofemoral arthrodesis for tuberculosis of the hip. Journal of Bone & Joint Surgery 50A: 1341 17. Chow S P, Yau A 1980 Tuberculosis of the knee--A long term follow-up. International Orthopaedics 4: 87-92 18. Wilkinson M C 1969 Tuberculosis of the hip and knee treated by chemotherapy, synovectomy and debridement. Journal of Bone and Joint Surgery 51A: 134331359