Orthopedics - Oleksa A.P. 2006

Bone and Joint Tuberculosis
General Principles of Conservative Treatment

With the Introduction of anti-tuberculosis chemotherapeutic agents into clinical practice, significant progress has been achieved in the Treatment of patients with Bone and joint Tuberculosis. The earlier a focus of tuberculous infection of any localization in the bone is detected, the more effective conservative treatment becomes. Chemotherapy is required in all phases of bone and joint tuberculosis, and treatment generally lasts for about a year.

The primary chemotherapeutic agents are isoniazid and rifampicin. They are prescribed to patients at 0.6 g per day (assuming a body weight of 60 kg) in one or two doses. Along with these medications, it is best to administer: 1) streptomycin (1 g per day intramuscularly); 2) ethambutol (1.2 g); and 3) pyrazinamide (0.5 g 4–5 times a day).

Reserve drugs are considered to be:

1) ethionamide (0.25 g 3–4 times a day); 2) prothionamide (0.25 g 3–4 times a day); 3) kanamycin (1.0 g intramuscularly); 4) viomycin (1.0 g intramuscularly); 5) capreomycin (1.0 g intramuscularly). Cycloserine (0.25 g 3–4 times a day) should be used with caution in patients with alcoholism and psychiatric disorders.

PAS is classified as a weak chemotherapeutic agent, therefore its daily dose is 12 g, along with thioacetazone (0.05 g 2–3 times a day).

In the treatment of patients with bone and joint tuberculosis, nine groups of antibacterial agents are used.

Group 1: derivatives of isonicotinic acid (isonicotinic acid hydrazide (INH)); thionamides of nicotinic acid: ethionamide, prothionamide, pyrazinamide, fluronizide.

Group 2: Aminoglycosides: streptomycin, kanamycin, amikacin, gentamicin, and tobramycin.

Group 3: Polypeptides: viomycin and capreomycin.

Group 4: Amino Acids: cycloserine, terizidone, terivalidine.

Group 5: oxamycins: rifampicin and its derivatives (anamycin, streptovaricin).

Group 6: PAS derivatives.

Group 7: ethylenediamines: ethambutol, myambutol, tibutol, combutol.

Group 8: thiourethanes: tibon, thiocarbazone, solutisone.

Group 9: new drugs: 7β-lactam derivatives (amoxicillin, femoxin, tienam, carbenicillin) and quinolones (ofloxacin, tarivid, zanocin, ciprofloxacin).

In clinical practice, patients are widely prescribed core drugs—isoniazid and rifampicin—as well as companion drugs—streptomycin, ethambutol, and pyrazinamide.

Reserve drugs are used in cases of intolerance or adverse reactions to the primary antibacterial agents.

The treatment regimen is planned individually for each patient, depending on the phase and activity of the tuberculous process, adhering to the following principles: 1) combination of chemotherapeutic agents to prevent microbial resistance; 2) two-stage treatment: a) performing a daily bactericidal phase; b) including an intermittent phase.

The average duration of chemotherapy is 10–12 months.

The World Health Organization (WHO) has proposed treatment regimens for four categories of patients.

Category I: patients with newly diagnosed severe forms of spondylitis.

The First stage of treatment includes: isoniazid 0.3 g 1–2 times a day, rifampicin 0.6 g, pyrazinamide 2.0 g, ethambutol 1.2 g, or streptomycin. The drugs are administered for two months until a positive clinical and radiological outcome is achieved.

The Second Stage of treatment: daily isoniazid combined with alternating-day rifampicin for 5–6 months. Rifampicin can be replaced with tibon or ethambutol.

Category II: patients with a relapse or exacerbation of the tuberculous process, or in the absence of an adequate response to treatment.

The first stage of treatment: isoniazid, rifampicin, pyrazinamide, streptomycin, ethambutol. In addition, quinolone-Class drugs (such as ofloxacin or ciprofloxacin) are prescribed for three months or until positive radiological dynamics are observed.

Second stage: isoniazid daily and ethambutol or rifampicin every other day for 5–6 months.

Category III: patients with newly diagnosed tuberculosis characterized by an indolent course.

First stage of treatment: isoniazid, rifampicin, pyrazinamide. Treatment is administered daily (or every other day) for two months at the above-mentioned doses.

Second stage of treatment: isoniazid, rifampicin (ethambutol) for 2–6 months, depending on the progression of the disease.

Category IV: patients with chronic tuberculosis and confirmed microbial resistance to chemotherapeutic agents. Fluoroquinolones (ofloxacin, ciprofloxacin) are prescribed along with macrolides (roxithromycin, erythromycin), which enhance the efficacy of chemotherapeutic drugs, or ß-lactams combined with phenasid or azophir.

V. Comprehensive patient management requires ensuring absolute rest for the affected spinal segment or joint. First and foremost, the patient must be informed about The Nature of the condition and the necessity of prolonged immobilization, taking into account their age and behavioral compliance.

In Tuberculous Spondylitis, the patient is placed in a custom-molded plaster bed, where they must remain continuously throughout the course of treatment. If spinous process prominence has already developed, the spinal gibbus can be eliminated or significantly reduced by progressively inserting increasingly thicker cotton-gauze or foam pads underneath. In some cases, plaster bed immobilization even leads to the recovery of limb movement in lower paraparesis, which is observed in nearly 1.5% of patients with spondylitis.

In Tuberculosis of the extremity joints—particularly in the arthritic and post-arthritic phases—the limb must be reliably and securely immobilized with a plaster cast in a functionally advantageous position. Such a cast promotes the resolution of inflammation, prevents The Development of antalgic contractures, and, in the event of joint ankylosis, preserves the limb in a functional position.

In tuberculosis of the hip joint, a plaster spica cast should extend up to the costal arches, while in knee joint involvement, a long leg cast should encompass the pelvis.

Plaster immobilization spanning two adjacent joints is also required for tuberculous lesions of other joints.

An enhanced, balanced, and vitamin-rich diet is essential to strengthen the patients' bodies and boost their reactivity and Immune Response. It is especially important for patients to consume adequate amounts of protein, along with reduced amounts of fats and CARBOHYDRATES. The body should be supplied with sufficient mineral salts, with a particular emphasis on calcium enrichment. Metabolic processes must be properly regulated.

Patients should Sleep with an open window and, whenever possible, rest outdoors in diffused sunlight. Heliotherapy in specialized climatic sanatoria is highly beneficial.

Due to prolonged bed rest, patients should undergo daily Muscle massage and Therapeutic Exercises (physical therapy), supplemented by physical therapy modalities when necessary, especially during the recovery phase. In elderly patients, symptomatic treatment targeting The Cardiovascular system and other internal organ pathologies should also be provided.