外科学课件：骨关节结核（英文版）

TuberculosisofBoneandJiont

Tuberculosis(TB)isstillacommoninfectionindevelopingcountries.Afterlungandlymphnode,boneandjointisthenextcommonsiteoftuberculosisinthebody.Itconstituteabout1~4%ofthetotalcasesofTB.Childrenandyoungpeople(<30yearsold)are80%inthepeoplesofTB

Thespineisthecommonestsiteofboneandjoint,constitutingabout50%ofthetotalnumberofTBcases.

Thenextinorderoffrequenyarethehip,thekneeandtheelbow.TBosteomyelitiseffectstheendofthelongbone,unlikepyogenicosteomyelitiswhichaffectsthemetaphysis.Thejointconstitutedabout30%ofthetotalnumberofTBcases.

PathologyTBinfectionoftheboneandsynovialtissueproducessimilarresponseasitproducesinthelungesie.,chronicgranulomatousinflammationwithcaseationnecrosis.Theresponesmaybeproliferative,exudativeorboth.1、Proliferativeresponese:Itischaracterisedbychronicgranulomatousinflammationwithalotoffibrosis.

2、Exudativeresponese:thereisextensivecaseationnecrosiswithoutmuchcellularreaction.

3、CaseationnecrosisNaturalhistoryTheinflammationresultsinlocaltrabecularnecrosisandcaseation.Intheabsenceofadequatebodyresistenceorchemotherapy,thecorticesofthebonegeteroded,andtheinfectedgranulationtissuesandpusfindtheirwaytothesubperiostealandsoft-tissueplane.Heretheypresentascoldabscesses,andmayburstouttoformsinuses.1、Coldabscesses

2、Pathologicalfracture

3、Pannus.Inflammatorysynoviumattheperipheryofthecartilage.Atubercularosteomyelitisinthevicinityofajointmayresultintheinvolvementofthejoint.Lowgradesynovitiswiththickeningofsynovialmembrane.CartilagehavebeenSlowlydestruied.

4、Fibrousankylosis

5、healingInvestigation

1、X-rayexamination:TBosteomylitis、TBarthritis.

2、Bloodexamination

3、SerumELLSAtestforantibodies

4、Synovialfluidaspiration

5、Aspirationofcoldabscess

6、HistopathologicalexaminationfrombiospyorcurettageofalesionTreatment1、Controlofinfection:Anti-TbdrugsincludingRifampicin,INH,thambutol，Pyrazinamide,Strptomycin.Rest.2、Careoftheaffectedpart:ProperpositionofthejiontMobilisationExerciseWeight-bearing:itisstartedgraduallyastheosteoporosissecondarytothediseaseisreversed3、Operativeintervention

Biospy

Treatmentofthecoldabscess

Curettageoftheleision

Jiontdebridement

Synovectomy

Salvageoperations

Decompression

TBofthespineThespineisthecommonestsiteofboneandjiontTB;Thedorso-lumbarregionbeingtheoneaffectedmostfrequentlyTypeofvertebraltuberculosisParadiscalCentralAnteriorPosteriorPathologyThebasicpathologyisthesameasthatinotherboneandjiontTB.Cllopseofthevertebra.Gennerallywedging.ColdabscessClincalfeaturesPainbackpainisthecommonestsyptom.Stiffnesspara-vertebalmusclegointospasmtopreventmovement.ColdabscessParaplegiaDefomitygibbusConstitutionalsymptomfever,weight-lossPhysicalexaminationGaitshortsteptoavoidjerkingthespineAttitudeanddiformityPatientwithcervicalTBhasastiff,straightneck.IndorsalspineTB,thespinebecomeprominent.Para-vertebralswellingTendernessMovementspinemovementislimited.Neurologicalexaminationlevel,severityGeneralexaminationinvestigationX-rayDestructionofthevertebralbody,coldabscess,rarefaction.CTscanMRIBiopsyGeneralinvestigationESR,CRP,TBIGg,ELLSAtest,chestX-raycomplication1、Coldabscess2、Neurologicalcompression(pottparaplegia)Treatment1、stable2、reconstractePrinciplesoftreatmentPrinciplesoftreatmentTopromoterecoveryoftheaffectedneuraltissue,byreversingthecauseresponsibleforcompression,eitherbydrugorbyoperation.Toachivehealingofthevertebrallesion,andtosupportthespinetillthediseasesegmentbecomestable.Decompression.Toundertakerehabilitativemeasurestopreventcontracture,andtoregainstrenghintheaffectedpart.1、Conservativetreatment

drug

2、Operation

debride

decompression

stablespineTuberculosisofthehipPathologyThebasicpathologyissame.Theusualintialisintheboneadjacenttothejionti.e.,eithertheacetabulumortheheadofthefemur.Insomecases,thelesionbegininthesynovinm,butthecartilageandthebonesareaffected.ApurelysynovialTBasseenintheknee,isuncommominthehip.Naturalhistory1、Thesynoviumhypertrophyandeffusion.Thecartilageisdestroyedandthejointbecomefullofpusandgranulationtissues.Thesynoviumgetthickened,oedematous,grayandulcerated.2、MulpiplecavitationSuchcavitiesareformedinthefomralheadandtheacetabulum.Eventuallytheheadandacetabulumgetobsorbed.Thejointdislocatedandtheneckoffomralgetfracture.Thepusmayperforatetheacetabulumandappearasapelvicabscess.3、Healingmaytakeplacebyfibrosis,leadingtoankylisisofthehipinadeformedposition.Clinicalfeature

1、Stiffnessofthehip,itproducesalimp.

2、Pain.Itmaybepainreferredtotheknee.Thechildmaycomplainofnightcry.Thomas征PE:Stiff-hipgait.Lamenessisthefirstsign.MusclewastingSwellingDischargingsinusesDeformityShorteningMovementsactiveandpassivemovementarelimited.StageofTBofthehipStageofsynovitisThereiseffisionintothejiont.Thisstageiscalledthestageofapparentlengthening.StageofthearthritisThisstageiscalledthestageofapparentshortening.StageoferosionThecartilageisdestroyedandtheheadortheacetabulumiserosion.Investigation

X-rayHaziness,Lyticlesion,reductionofjiontspace,Irregularoutline,Acetabularchange.RoutinalinvestigationbiospyPrincipleofTreat