SLR - August 2019 - Mahsa AghaJafari

Arthroscopic Management for Early-Stage Tuberculosis of the Ankle

Reference: Xiaojun Duan, Liu Yang. Arthroscopic Management for Early-Stage Tuberculosis of the Ankle. Journal of Orthopedic Surgery and Research. 2019 Jan 22;14(1):25

Scientific Literature Review

Reviewed By: Mahsa AghaJafari, DPM
Residency Program: Maricopa Medical Center/Creighton University – Phoenix, AZ

Podiatric Relevance: Joint tuberculosis (TB) accounts for approximately 3 percent of extra-pulmonary TB and although foot and ankle osteoarticular tuberculosis is uncommon, late diagnosis and management can lead to significant morbidity and deformity. Preservation of limb function can be achieved by prompt diagnosis. Therefore, it is important for podiatrists to promptly and correctly diagnose such cases if clinical suspicion of TB is present in the setting of ankle pain and chronic synovitis. This article reviews the use of arthroscopy for diagnosis and treatment of early stage ankle TB. The purpose of arthroscopy is to directly observe the lesion, make relevant examinations, and perform arthroscopic debridement of necrotic tissue, which could improve effectiveness of anti-TB drugs and be an adjunct to local disease control.

Methods: This is a retrospective case series of 15 patients who underwent ankle arthroscopic treatment of TB from 2010 to 2016. Patients presented with chronic ankle synovitis where inflammatory and traumatic origins were ruled out and a suspicious cause of early-stage ankle TB was present. Patients with sinus, sequestrum, and bone destruction that required additional debridement, low compliance of anti-TB drugs, and active pulmonary TB were all excluded. All cases had failed to confirm diagnosis of TB by ankle arthrocentesis and subsequently underwent arthroscopy including synovial membrane biopsy and debridement. Final diagnosis was confirmed by pathologic examination and culture. All cases were additionally treated with systemic anti-tuberculous medication. Follow-up measurements included VAS score, AOFAS score, ESR, CRP, and MRI.

Results: Thirteen out of 15 cases successfully confirmed TB by pathologic examination and culture, and two cases still remained clinically suspicious for TB, but were undiagnosed. Therefore, 87 percent of the total cases that could not be diagnosed by ankle arthrocentesis preoperatively were confirmed through arthroscopy. Additionally, post treatment, there were significant differences between preoperative scores and final follow-up scores for VAS , AOFAS , ESR, and CRP (p-value <0.01 for all measures). Joint swelling resolved after two months in most patients. MRI suggested all patients who had articular effusion and bone edema pre-operatively, had their effusion and edema significantly reduced after treatment. No recurrent TB was found during follow-ups.

Conclusion: Tuberculosis remains a major global problem. Diagnosis of tuberculous infection in a joint is difficult due to its atypical clinical presentation; therefore, it is important to have high clinical suspicion and to promptly diagnose and treat these cases to preserve limb function. Podiatrists evaluate many patients with ankle pain and although a wide range of differential diagnoses exist, if ankle TB is suspected due to presence of pain, ankle synovitis, or other organ manifestations of TB, early diagnosis and treatment should be initiated. Arthroscopy may offer diagnostic value for suspected TB cases that cannot be confirmed by ankle arthrocentesis. It is a minimally invasive, relatively safe, and reliable procedure which can yield samples for confirmation of diagnosis and may additionally assist in local disease control through debridement.

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