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Scientific Articles   |    
Tuberculosis of the Elbow Joint in ChildrenA Review of Ten Patients Who Were Managed Nonoperatively
Anil Agarwal, MS(Ortho)1; Imran Mumtaz, MS(Ortho)1; Pawan Kumar, Dip(Ortho)1; Shariq Khan, Dip(Ortho)1; Nadeem Aktar Qureshi, Dip(Ortho)1
1 Department of Orthopaedics, Chacha Nehru Bal Chikitsalaya, Geeta Colony, Delhi, India-110031. E-mail address for A. Agarwal: rachna_anila@yahoo.co.in
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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

Investigation performed at the Department of Orthopaedics, Chacha Nehru Bal Chikitsalaya, Geeta Colony, Delhi, India

Copyright ©2010 American Society for Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2010 Feb 01;92(2):436-441. doi: 10.2106/JBJS.I.00805
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Abstract

Background: 

There is scarce information regarding osteoarticular tuberculosis of the elbow in children, even in countries where tuberculosis is endemic. We report our experience with ten patients who were managed nonoperatively.

Methods: 

We retrospectively assessed ten children with elbow tuberculosis with regard to their presentation, diagnosis, management, response to standard antitubercular drugs, and outcome at the completion of antitubercular therapy. All patients were managed nonoperatively with splinting for as long as six weeks, followed by mobilization along with multidrug antitubercular medication for twelve months.

Results: 

Swelling of the elbow that did not respond to initial treatment was the most common cause for referral to our clinic. The proximal ulnar metaphysis was most commonly involved. The average duration of follow-up was twenty-six months. The average time for healing of draining sinuses was twelve weeks (range, four to fourteen weeks). Lytic lesions, including coke-like sequestrum, healed radiographically at an average of 7.4 months (range, six to nine months). Range of motion improved with treatment, but some motion restriction always persisted, depending on the extent of joint destruction.

Conclusions: 

In the Indian subcontinent, the presentation of elbow tuberculosis is usually exudative with abscess formation, and the disease is fairly advanced at the time of diagnosis. An "ice cream scoop" appearance of the proximal part of the ulna in children should raise suspicion for tuberculosis. Elbow tuberculosis in children can be treated adequately with use of nonoperative means, regardless of the extent of osseous destruction, with a good outcome.

Level of Evidence: 

Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

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    References

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Anil Agarwal, MS(Ortho)
    Posted on March 16, 2010
    Dr. Agarwal and colleagues respond to Dr. Gulati
    Chacha Nehru Bal Chikitsalaya, Geeta Colony, Delhi, India

    We thank Dr. Gulati for his interest in the topic and our article (1). The biopsy under general anesthesia was performed only in 6 patients. The diagnosis of tuberculosis was not evident at time of performing biopsy. Hence, a biopsy was undertaken to obtain tissue for diagnosis. The high positivity for culture obtained in our series is probably because of the multiple samples and tissues which were tested. No atypical mycobacterium was isolated. Many of our patients with sinuses had been given broad spectrum antibiotics for many weeks. This may have led to negative gram stains. We do agree that enlargement of the lymph nodes has been described in association with tuberculosis of the elbow (2,3) but, in the current series, enlargement of lymph nodes was not noted. Two patients in our series were started on antitubercular chemotherapy based on clinical and radiographic findings. The histopathology reports at our institution were available by 4-5 weeks. The patients in whom a typical tubercular granuloma was seen on histopathology were started on antitubercular treatment and the diagnosis reconfirmed on isolation of acid fast bacteria. Our patients with multifocal tuberculosis were screened for immunodeficiency and all were found to be fully immunocompetent. The patients were treated according to the Revised National Tuberculosis Programme advocating Directly Observed Treatment (DOT) for bone and joint tuberculosis. The continuation phase was extended further in view of evidence available for prolonged therapy from this region (4).

    References

    1. Agarwal A, Mumtaz I, Kumar P, Khan S, Qureshi NA. Tuberculosis of the elbow joint in children: a review of ten patients who were managed nonoperatively. J Bone Joint Surg Am. 2010;92:436-41.

    2. Patel DA. The supratrochlear lymph nodes: their diagnostic significance in a swollen elbow joint. Ann R Coll Surg Engl. 2001;83:425-6.

    3. Aggarwal A, Dhammi I. Clinical and radiological presentation of tuberculosis of the elbow. Acta Orthop Belg. 2006;72:282-7.

    4. Tuli SM. General principles of osteoarticular tuberculosis. Clin Orthop Relat Res. 2002;398:11-9.

    Divesh Gulati, MS(Ortho)
    Posted on March 01, 2010
    Nonoperative Management of Tuberculosis of Elbow Joint in Children
    University College of Medical Sciences, Delhi, India

    To the Editor:

    I read with interest the article by Agarwal et al. (1) regarding the nonoperative management of tuberculosis of the elbow in children. There are conflicting reports in literature (2,3) regarding the need for and adequacy of debridement and synovectomy for the elbow joint considering that chemical debridement by anti tubercular therapy (ATT) suffices. But since the authors decided to perform an open bone and synovial biopsy instead of Fine Needle Aspiration Cytology, a debridement and curettage of the bony lesions or sequestrectomy could have helped to decrease the disease load and speed in recovery (2). Tuberculosis of the elbow classically starts as synovitis with rice bodies and synovial effusion with subsequent involvement of bone (4). It would be interesting to know whether the cultures that were positive for Acid Fast Bacilli (AFB) were obtained from synovial tissue, synovial fluid or bone. Was any atypical mycobacterium isolated? The authors report a very high AFB culture positivity rate in their patients (80%). Osteoarticular tuberculosis is generally considered a paucibacillary disease and low positive culture rates have been reported even in endemic areas similar to the authors’ geographical area (12% in a study by Jain et al. (5) and 49% by Lakhanpal et al. (6)). In addition, eight patients had a history of antibiotic intake which would have made the culture of AFB even more difficult. Moreover, it was interesting to note that the authors did not find any positive gram stain and aerobic cultures and no supratrochlear lymphadenopathy considering that four patients had a sinus which had persisted for at least two months and is likely to be associated with superadded pyogenic infection (4). The authors based their diagnosis of tuberculosis on positive AFB cultures. Cultures usually take about 6-8 weeks to demonstrate positivity (5). Were the patients started on ATT in the meanwhile based on clinical or radiographic findings? Were the histopathology reports taken into consideration for start of treatment as histopathology has a sensitivity rate ranging from 72-97% (5) and provides earlier diagnosis than AFB cultures? Three patients in the authors’ series had multifocal tuberculosis with two patients having pulmonary involvement. Were these patients investigated for immunocompromised status including human immunodeficiency virus infection? I would also like the authors to comment on the duration and frequency (daily or alternate day regime) of ATT for tuberculosis of elbow joint and if there was any basis for prescribing ATT for 12 months.

    The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated.

    References

    1. Agarwal A, Mumtaz I, Kumar P, Khan S, Qureshi NA. Tuberculosis of the elbow joint in children: a review of ten patients who were managed nonoperatively. J Bone Joint Surg Am. 2010;92:436-41.

    2. Chen WS, Wang CJ, Eng HL. Tuberculous arthritis of the elbow. Int Orthop. 1997;21:367-70.

    3. Martini M, Benkeddache Y, Medjani Y, Gottesman H. Tuberculosis of the upper limb joints. Int Orthop. 1986;10:17-23.

    4. Tuli SM. General principles of osteoarticular tuberculosis. Clin Orthop Relat Res. 2002;398:11-9.

    5. Jain AK, Jena SK, Singh M, Dhammi I, Ramachadran V, Dev G. Evaluation of clinico-radiological, bacteriological, serological, molecular and histological diagnosis of osteoarticular tuberculosis. Indian J Orthop. 2008;42:173-7.

    6. Lakhanpal VP, Tuli SM, Singh H, Sen PC. The value of histology, culture and guinea pig inoculation examination in osteo-articular tuberculosis. Acta Orthop Scand. 1974;45 36-42.

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