[Tuberculosis of the wrist. Symptoms and outcome in eleven cases]. / Tuberculose du poignet. Symptômes et évolution de 11 cas.

PURPOSE OF THE STUDY: We present our experience with a rare localization of tuberculosis, the wrist, focusing on symptoms and outcome after treatment. MATERIAL AND METHODS: Our series included eleven patients, eight men and three women, mean age 42 Years, who presented tuberculosis of the wrist. Tuberculosis was known in four patients who were being treated and a context of tuberculosis was recognized in three others. One patient on long-term corticosteroid therapy was immunodepressed. Mean time from symptom onset to consultation was fifteen months indicating a slow and progressive disease process. An inflammatory syndrome was noted in nine patients. Based on the standard x-rays, the David-Chausse classification was: stage I n=1; stage II n=1; stage III n=3; stage IV n=4. The AP view of the wrist was normal in two patients. Diagnosis of tuberculosis was confirmed on the surgical biopsy specimen which revealed epithelio-gigantocellulary granuloma with caseous necrosis. In only five patients Koch bacilli developed in culture on Lowenstein-Jensen. Patients were given anti-tuberculous antibiotics and the wrist was immobilized in a plaster splint. RESULTS: Mean follow-up was two years. The disease course was blunted by the antituberculosis treatment. Surgical drainage was only required to clear abscesses. Wrist stiffness was frequent and had a significant functional impact. DISCUSSION: These eleven cases of a rare localization of tuberculosis illustrate the slow progressive course of clinical symptoms and radiological signs of tuberculosis, emphasizing the difficulties encountered in establishing early diagnosis of such isolated non-abscessed localizations. Anti-tuberculous treatment is effective but the functional outcome depends on early diagnosis before the development of radiological evidence of joint destruction.

Tuberculosis of the hip.

Tuberculosis of the hip constitutes approximately 15% of all cases of osteoarticular tuberculosis. The common age of presentation is in the second and third decades. In Stages II and III of the disease, the radiologic features are very obvious and diagnostic, and almost always predict the final clinical outcome. A progressive pattern of destruction of the hip occurs in patients who are not treated. Treatment must be instituted early with an aim of salvaging the hip. Treatment comprised of drug therapy, traction, and supervised mobilization produces good results in patients with early stages of the disease. Patients who do not have a favorable clinical response to conservative treatment should have surgery before the hip is destroyed. In the eastern hemisphere, patients prefer a painless but mobile joint, for satisfying the customary needs of squatting, sitting cross-legged, and kneeling. Therefore, excision arthroplasty produces satisfactory results as compared with hip arthrodesis. Total hip arthroplasty should be considered only after a safe period of absolute disease quiescence.

Sacroiliac joint tuberculosis. Classification and treatment.

The authors treated 16 patients with tuberculosis of the sacroiliac joint. Twelve were treated surgically and four were treated conservatively. The clinical symptoms were buttock and low back pain in all patients, and most had difficulty walking (68.6%) and had radicular pain in their lower limbs (50%). Of the 16 patients, four (15%) had associated tuberculous spondylitis, six (37.5%) had an abscess in the gluteal region, and two (12.5%) had an abscess in the inguinal region. The diagnosis was proven by pathologic specimen in 12 patients and by clinical symptoms, laboratory data, and radiologic findings in the remaining four patients. The authors classified tuberculous sacroiliitis into four types based on the clinical and radiologic findings. Types 1 and 2 were treated conservatively with chemotherapy alone, whereas Types 3 and 4 were treated with surgery and chemotherapy. Healing occurred and was evident in patients who had curettage and arthrodesis (Types 3 and 4) at a mean of 20.8 months, which was comparable with healing in the patients who had chemotherapy alone that occurred at a mean of 23.5 months (Types 1 and 2). The authors suggest that the new classification will be helpful in determining the therapeutic plan of tuberculous sacroiliitis.

[Bone and joint tuberculosis in Hungary today]. / A csont-ízületi gümökór ma Magyarországon.

Authors introduce to the history of efforts against tuberculosis in Hungary. The effectiveness of this figh is shown by the decrease of morbidity rates. The decrease of morbidity rates was followed by the cutting down of the system of institutions devoted to the conquest of tuberculosis. Authors give account on the present epidemiological conditions and report on the four and a half years activity of their bone and joint surgery department in this field. The department proved to be reliably suitable for the treatment of patients with bone and joint tuberculosis. They draw the attention to the significance of yearly 30 cases which show that the tuberculosis did not yet disappear from Hungary. The aim of the paper is to maintain the problem in the common medical consciousness.

Atlanto-axial tuberculosis in adults.

Twelve adult patients with confirmed tuberculosis of the atlanto-axial spine are presented and a classification proposed. Stage I has minimal ligamentous or bone destruction and no displacement of C1 on C2; the suggested treatment is transoral biopsy and decompression followed by an orthosis. Stage II has ligamentous disruption and minimal bone destruction but anterior displacement of C1 on C2; treatment involves transoral biopsy and decompression, reduction by halo traction, then a posterior C1-2 fusion. Stage III has marked ligamentous and bone destruction with displacement of C1 forward on C2; the suggested treatment is transoral biopsy and decompression, reduction by halo traction, then fusion from the occiput to C2 or C3. One patient died before treatment started; all the others have gone on to solid union with resolution of any neurological deficit. There has been no evidence of reactivation of disease over an average follow-up of 36 months.