Orthopedics - Oleksa A.P. 2006

Joint Diseases
Infectious Arthritides of Known Etiology
Syphilitic Arthritis

Syphilitic Arthritis is extremely rare in clinical practice today, largely due to well-established treatments for Syphilis.

Syphilis is a chronic infectious disease caused by the spirochete Treponema pallidum. The disease follows a characteristic course: an incubation period, the primary stage marked by a chancre (initial lesion), a secondary stage, and a latent period (hidden syphilis), the duration of which depends on the body's overall reactivity and the effectiveness of Treatment. If left untreated, the latent period is punctuated by periodic flare-ups and eventually progresses to the tertiary stage.

The Musculoskeletal System can be affected in both congenital and acquired syphilis.

It is practical to follow S.A. Reinberg's simple Classification of syphilitic bone lesions: 1) periostitis (gummatous and diffuse); 2) osteitis (gummatous and diffuse); 3) Osteomyelitis (localized gummatous and diffuse). B.M. Pashkov further subdivides these into various forms: syphilitic diaphysitis, metaphysitis, epiphysitis, and osteochondritis.

Two MAIN TYPES OF inflammatory processes are observed in syphilitic bone disease: 1) a proliferative-exudative process of a productive-hyperplastic nature (in secondary relapsing syphilis), characterized by The formation of bone surface layers (hyperplastic periostitis); and 2) a proliferative-alterative process presenting as gummatous destruction (in tertiary syphilis). Initially, an infiltrate forms in the osteogenic layer of the periosteum, featuring central caseous necrosis, bone destruction, and surrounding reactive osteosclerosis.

Clinical symptoms. Clinically, periostitis may manifest as localized or widespread bone thickening that is extremely tender to the Touch. A hallmark sign is nocturnal pain that diminishes during the day and with movement (unlike in tuberculosis). The overlying Skin is edematous and tense, leaving an indentation when pressed with a finger. Local Temperature remains normal.

On radiographs, diffuse periostitis appears as a broad ossified band running parallel to the bone without fusing with it, sometimes resembling onion-skin layering in cross-section. Localized periostitis may also occur as a crest-like formation resulting from transverse bands.

Gummatous periostitis is characterized by solitary or multiple gummas that connect with the cortical or even cancellous bone. It is round in shape with central osteonecrosis and surrounding sclerosis, creating a mosaic pattern known as "lace-like" periostitis.

Syphilitic osteitis and osteoperiostitis occur in tertiary and late congenital syphilis. A classic manifestation is saber shins (anterior bowing of the tibiae). Due to chronic inflammation, the entire Tibia becomes thickened, elongated, and curved under body weight during growth. Radiographs reveal diffuse osteosclerosis.

Gummatous osteitis (Fig. 321) is typically associated with a subperiosteal specific process and appears on radiographs as a "saucer-like" oval, translucent, featureless defect. Gummatous osteomyelitis usually manifests as multiple destructive foci within the Bone Marrow surrounded by a rim of sclerosis.

Epiphyses, Phalanges, metacarpal, and Metatarsal Bones are very rarely affected by syphilis.

Syphilitic joint involvement can occur at any stage of the disease. Specific inflammation may be confined to the synovial membrane and Joint Capsule without damaging the Cartilage and bone (chronic synovitis, gummatous synovitis, acute syphilitic polyarthritis).

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Fig. 321. Radiograph of syphilitic arthritis of the elbow joint with gummatous-destructive osteitis of the ulna.

Synovitis arises primarily and exhibits a torpid course with minimal clinical signs of inflammation (no fever, pain, or functional Impairment of the joint). Mild nocturnal pain and symptoms of joint effusion predominate.

Gummatous synovitis is rare and accompanied by villous proliferation of the synovial lining. The Diagnosis is confirmed by synovial fluid analysis using the Wassermann reaction.

Syphilitic osteoarthritis manifests as the destruction of subchondral bone and epiphyses. The articular cartilage is damaged secondarily. Despite significant destructive changes, joint pain is typically absent, and joint mobility remains preserved. The joint space is slightly widened. Unlike tuberculous and pyogenic arthritis, syphilitic arthritis does not lead to contractures or ankylosis.

Syphilitic arthritides include Tabetic arthropathy, which occurs in the late stage of the disease. It is characterized by joint enlargement due to effusion and subsequent deformity. Pain occurs upon joint pressure. Over time, the surrounding Muscles atrophy, and joint laxity becomes so pronounced that the patient, despite lacking pain, loses control of the limb. Clinical signs of inflammation are absent. The synovial fluid is turbid with tissue debris. Radiographs reveal very characteristic destruction of the articular ends of the bones with the Separation of large sequestra and joint destruction, which may lead to subluxations and dislocations.

Infants with congenital syphilis may develop specific osteochondritis (of the growth plate), characterized by delayed cartilage regression and increased calcium deposition within cartilage Cells. As a result of this osteochondritis, the epiphysis may separate from the diaphysis within the first weeks of life, leading to Parrot's pseudoparalysis. The affected arm hangs limply, movements are painful (causing the child to cry), yet clinical neurological deficits are absent and finger movements are preserved. The lower limbs are rarely affected. These symptoms may be the sole early indicator of congenital syphilis.

In children aged 4 to 16, congenital syphilis manifests as periostitis and osteoperiostitis, gummatous osteomyelitis, classic saber shin deformities of the lower legs and forearms, and chronic hydrarthrosis. Diagnosis is facilitated by the presence of Hutchinson's triad and a positive Wassermann reaction.

Treatment for patients with Bone and joint syphilis is based on General Principles of venereology. The administration of high doses of Antibiotics and specific targeted therapy leads to complete remission and the Prevention of relapses.