Tuberculosis infection complicating primary total knee arthroplasty - report of 2 unusal cases and review of the literature Dr.Sunil singh thapa Lecturer Department of orthopedics Sports and arthroplasty unit TUTH

Introduction Primary tubercular osteo-arthritis is well known, while periprosthetic tubercular infections are uncommon Delay in diagnosis is typical, and can usually be attributed to a low index of suspicion

Tuberculosis often does not cause early component loosening and patients could be treated successfully with prosthesis conservation. On the contrary, when diagnosis is late, tubercular osteomyelitis can induce severe bone damage with poor functional results.  

Here we report 2 unusual cases of periprosthetic tuberculosis in primary total knee replacement done for osteoarthritis . There were no local or systemic evidence of tuberculosis at the time of index surgery.

Case 1 78 yr old lady B\L severe knee osteoarthritis(without instability) B/L primary total knee replacement in same settings No intra op and post op complications

Case 1

Asymptomatic for 3 months post index surgery Presented with dull aching pain and swelling over RT. Knee and asymptomatic left knee

-Boggy swelling around medial aspect of proximal tibia -local warmth Rt. Knee examination -Boggy swelling around medial aspect of proximal tibia -local warmth -ROM-0-80degree Aspiration reveals-turbid fluid Culture –no growth I/V antibiotics RT LT

Right knee(4 month f/u) Left knee(4 month f/u)

RT knee debridement with component retention was done Tissue was sent for culture and histopathology Histopathology report –granulomatous lesion consistent with tuberculosis

After debridement

ATT Hinge knee brace support with walker mobilization Regular dressing of discharging sinus

5 month f/u

1 yr follow up

Case 2 68 yr old male Right knee Osteoarthritis Total knee replacement No intra op and immediate post op complications

PRE-OP X-ray Early post op x-ray

F/U at 6 month 1 year

Asymptomatic for 13 month , presented with knee pain and swelling O/e Right knee: grade III effusion, tender medial joint line, ROM 0-80 degrees Knee aspiration reveals-straw color fluid Fluid analysis and culture report-normal

13 month F/U

14 MONTH F/U

PCR- analysis of synovial fluid-positive for Mycobacterium tuberculosis ATT started

Debridement, component removal with placement of Cement spacer done after 5 wks Of ATT

After 6 wks,revision TKR was done with metal wedge for bone loss on medial tibia.

Reported a case of 73 yr old lady, presenting with painful swollen knee after 14 yrs of TKR, Synovial fluid analysis and culture were negative, but PCR of the fluid was positive for tuberculosis Recovered well after ATT with brace immobilization Concluded that ,periprosthetic tuberculosis can be successfully managed conservatively provided there is no implant loosening

Knee arthroplasty was performed with the presumed diagnosis of osteoarthritis in all 3 cases Tuberculosis infection of the prosthesis diagnosed after 9 months in case 1, 6 months in case 2, and 5 months in case 3. All 3 patients responded to antituberculous therapy Two patients underwent successful 2-stage revision arthroplasties Third underwent aggressive synovectomy and debridement.

In some cases, tissues trauma related with arthroplasty surgery could cause local reactivation of previous unrecognized tuberculosis, mimicking an early periprosthetic infection (Hugate R., Jr., Pellegrini V.D., Jr. Reactivation of ancient tuberculous arthritis of the hip following total hip arthroplasty: a case report. Journal of Bone and Joint Surgery. 2002;84-A:101–105)

The infection could have been the consequence of local extension, hematogenous spread, or reactivation of latent disease in the knee ( Johnson R, Barnes KL, Owen R: Reactivation of tuberculosis after total hip replacement. Bone Joint Surg Br 61:148, 1979) ( Khater F.J., Samnani I.Q., Mehta J.B., Moorman J.P., Myers J.W. Prosthetic joint infection by Mycobacterium tuberculosis: an unusual case report with literature review. Southern Medical Journal. 2007;100:66–69)

Misdiagnosis is common, and arthroplasty is occasionally performed on an unsuspected affected joint, causing reactivation of the disease (Besser ML: Total knee replacement in unsuspected tuberculosis of the joint. Br Med J 280:1434, 1980 ) ( Wray CC, Roy S: Arthroplasty in tuberculosis of the knee: two cases of missed diagnosis. Acta Orthop Scand 58:296, 1987)

Single stage joint replacement can be used to treat active joint TB? M tuberculosis divides once in 15-20 hours which is slow when compared to S.Aureus which is 20 min. TB Bacilli form biofilm that differs from other pyogenic organisms Ha et al TB bacilli rarely or don’t adhere to the metal surface and rarely forms or don’t form biofilm. Ma et al study found that no biofilm formation for M tuberculosis on the surface of cobalt-chromium-molybdenum alloy or titanium alloy Metal implants have been used successfully in TB Spondylitis patients. (Yi-chao Zhang, MD; Hong Zhang MD; One stage Total joint arthroplasty for patients with active tuberculosis.,healio.com, Vol 36 Issue 5, May 2013) (Ha KY, Chang YG et al, Adherence and biofilm formation of S.Epidermidis, M tuberculosis on various spine implants, Spine ( Phila Pa 1976), 2005; 30(1): 38-43)

Pre op TB regimen should be for at least two weeks so that inflammatory markers (ESR and CRP) show positive reaction and post-operative regimen should be for minimum of 12 - 15 months. (Neogi DS, Yadav CS, Kumar A, THR in patients with active TB of hip with advanced arthritis, CORR, 2010; (468): 605-612)

Su et al reviewed 15 patients with 16 TKR……. Group I of 8 knees had active TB and treated pre operatively and post operatively with anti TB regimen. Group II of 8 knees included cases with no active TB hence no anti TB regimen given pre operatively but as they were diagnosed to have TB after surgery they were administered TB drugs post operatively. Group I had one relapse due to steroid intake. Group II had four relapses. (Su JY, Huang TL, Lin SY, Total knee arthroplasty in tuberculous arthritis, CORR,1996 (323) 181-187)

In our case, before diagnosis of tubercular periprosthetic joint infection all were treated empirically with antibiotics, and tuberculosis was not suspected at time of surgery Delay in diagnosis is typical, and can usually be attributed to a low index of suspicion (Walker GF: Failure of early recognition of skeletal tuberculosis. Br Med J 1:682, 1968)

Thus diagnostic work up for detection of M Thus diagnostic work up for detection of M. tuberculosis (histology, culture, and possibly molecular biology techniques) must be performed in persistent prosthetic joint infections, even in the absence of previous clinical history of tuberculosis

Controversy prevails regarding, Conservative vs Revision Single stage vs. Two stage revision Duration of pre-op /post –op ATT