Orthopedics - Oleksa A.P. 2006

Osteoarticular Tuberculosis
Tuberculosis of the Shoulder Joint

Tuberculous omarthritis (omarthritis tuberculosa) is rarely encountered in clinical practice, accounting for about 1.5% of all localizations. Right-sided omarthritis is more commonly diagnosed in middle-aged men.

Tuberculosis of the shoulder joint begins with primary osteitis in the region of the greater tubercle or epiphysis, and very rarely affects the lower part of the glenoid margin of the scapula. Occasionally, primary involvement of the synovial membrane of the joint is observed.

In the shoulder joint, the tuberculous process typically proceeds as a granulocellular type (caries sicca) and less frequently as the predominantly exudative type (fungus).

Caries sicca occurs in adults and has a subacute, protracted course. Although it is a milder process, the lesion gradually enlarges and may eventually rupture into the joint cavity.

In the exudative type of omarthritis, involvement of the synovial membrane and its recesses, along with communicating bursae, predominates; this manifests as tissue edema and suppuration of the joint. The process progresses more rapidly, and the abscess may break through downwards into the periarticular Tissues or track along the tendon of the long HEAD of the biceps brachii Muscle.

While caries sicca has a mild, protracted course, the fungous type of tuberculosis is characterized by an acute, pronounced clinical course featuring marked exudation and joint destruction.

Early signs of shoulder joint tuberculosis include joint pain and impaired arm function, particularly restricted abduction and lateral Rotation of the shoulder resulting from antalgic contracture of the subdeltoid, deltoid, and pectoralis major Muscles. As the disease progresses, a persistent arthrogenic contracture develops, accompanied by pronounced Atrophy of the shoulder girdle muscles.

In caries sicca, these symptoms are less pronounced and appear later; therefore, in the initial phase of the disease, X-ray Examination reveals little beyond Osteoporosis—which is also common to other pathological processes—making the Diagnosis of tuberculosis rather difficult.

Only later are localized intraosseous lesions with a sclerotic rim detected.

In the exudative type of tuberculosis, radiographs initially show widening of the joint space due to exudation, followed by a pronounced destructive process in the head of the humerus. The intraosseous abscess breaks into the joint, resulting in classic tuberculous omarthritis, which may also involve the articular surface of the scapula.

The initial phase of tuberculous involvement of the shoulder joint often requires differentiation from non-specific Arthritis, scapulohumeral periarthritis, tumors, plexitis, arthropathies, etc.

Non-specific inflammation of the shoulder joint begins acutely with high body Temperature, severe pain, and an inability to even move the arm due to pain. In cases of suppurative arthritis, the diagnosis is confirmed by joint puncture and bacteriological Analysis of the punctate.

In scapulohumeral periarthritis, similar clinical signs may be detected, but X-rays do not show widening of the joint space or destructive Changes in the shoulder joint. Occasionally, calcific bursitis in the area of the greater tubercle of the humerus may be present.

In osteoclastomas and chondroblastomas, which frequently localize in the proximal metaepiphysis of the humerus, pain occurs, but the range of motion in the shoulder joint remains normal, and there are no signs of an inflammatory process. Radiography reveals Characteristic Features of these tumors.

In arthropathies, patients never experience pain, even though the destruction of Cartilage and articular ends can be very pronounced radiographically. In addition to joint destruction, free sequestra floating in the synovial fluid may be present. Clinically, the joint is swollen and painless, occasionally exhibiting pathological mobility and subluxation.

Treatment. Timely detected osteitis of the humeral head, especially in children, is treated with a combination of conservative measures. Along with antibacterial drugs and general tonic therapy, the limb is immobilized with a plaster or plastic cast in a functionally advantageous position (abduction — 60°, anterior deviation — 45°, lateral rotation — 45–60°).

After the subsidence of the process—which is observed within 8–10 weeks in mild cases or 3–5 months in exudative cases—gradual recovery of the patient ensues. At this point, the cast is removed, and mobilization of the limb joints is initiated. Initially, passive abduction of the shoulder and flexion of the forearm are performed, after which the patient must perform active movements in all planes several times a day. The patient continues to take chemotherapeutic agents According to the prescribed regimen until full recovery.

In cases of extensive destruction of the shoulder joint by tuberculosis, the cast is not removed until the process subsides and fibrous ankylosis of the joint is achieved in a functionally advantageous position of the arm.

In exudative, rapidly progressing tuberculosis, surgical intervention is necessary from the moment abscesses and cold abscess formations appear.

Surgery involves the removal of all necrotic tissues, granulations, and the abscess. The surgical approach to the shoulder joint is made via the deltopectoral groove (sulcus deltoideo-pectoralis) with division of the subscapularis tendon. The Joint Capsule is excised, and necrotomy is performed while preserving the tendon of the biceps muscle.

In tuberculous involvement of the synovial membrane, active and passive movements in the joint can be initiated as early as 5–6 weeks after synovectomy (capsulectomy). The same approach is applied in cases of minor articular cartilage destruction following focal necrotomy.

If the articular surfaces are significantly destroyed, arthrodesis of the shoulder joint is performed in a functionally advantageous position of the limb. The bone ends, brought into contact after necrotomy, are sometimes fixed with screws, but in most cases, the limb is immobilized with a thoracobrachial cast until bony fusion of the articular ends is achieved.