Orthopedics - Oleksa A.P. 2006

Bone and Joint Tuberculosis
Treatment of Cold Abscesses and Fistulae

Cold migration abscesses most frequently occur in Tuberculous Spondylitis and coxitis As a result of significant destructive changes caused by late-detected and untreated tuberculosis.

As previously mentioned, pus and caseous masses can track along interfascial planes away from the site of the affected bone.

Depending on the duration and activity of the tuberculous inflammatory process, the volume of pus can vary significantly (even up to 1 L or more), and in spondylitis, it can track down as far as the popliteal fossa. In lesions of more superficial bones, such as in trochanteric bursitis, it does not track as far and may rupture through the Skin, forming a purulent sinus tract. The contents of a migration abscess, In addition to pus, may include caseous masses and bone sequestra. The older the abscess, the thicker the pus.

Puncture is used to confirm the presence of pus, determine its nature and volume, and perform Cytological examination. To trace The pathway of its extension, contrast abscessography or fistulography is performed.

The management of a migration abscess depends on its distance from the primary tuberculous bone lesion. For instance, in tuberculous trochanteric bursitis or gonitis, the abscess is excised simultaneously with the bone surgery. In tuberculous spondylitis or coxitis, the abscess may be located far from the affected bone, and a different strategy is applied. The abscess is aspirated, irrigated, and a solution of antibacterial agents is injected into its cavity after each puncture.

To prevent a large abscess from tracking further and destroying soft Tissues, the migration abscess is opened under local anesthesia with a 0,5 % novocaine solution. The pus is evacuated, and the abscess cavity is irrigated under pressure with a 1:5000 furacilin solution. The wound is drained using a tube through which a streptomycin solution is daily instilled in the hope that it will reach the primary focus.

Abscessotomy is a palliative measure, as pus from the tuberculous bone focus continues to form and discharge through the resulting sinus tract; therefore, the patient should be prepared for surgery on the affected bone.

The patient undergoes comprehensive conservative Treatment, including immobilization, antibacterial therapy, and general supportive care.

If The activity of the tuberculous process is low, the patient is operated on after their general condition improves.

Under general anesthesia, standard surgical approaches to both the spine and the hip joint are performed. Sequestronecrectomy of the affected vertebrae or hip joint is carried out, the technique of which has been described above.

These Procedures are supplemented only by the removal of the abscess containing caseous masses and sequestra, as well as the pyogenic membrane with granulation tissue within safe reach. If the direction of the interfascial tract of the abscess has been identified, it should be irrigated under pressure with a 1:5000 furacilin solution and an antibiotic.

Evidence that the purulent tract has been correctly identified is the leakage of the furacilin solution through the sinus.

Surgery on the spine or hip joint is completed by closing the wound and immobilizing the operated segment.

Following radical surgery on the spine or hip joint, the interfascial tract of the abscess—provided a pyogenic capsule with granulation and scarring has not yet formed—may collapse and scar down as a result of comprehensive conservative treatment. Such a favorable prognosis is indicated by a sharp decrease in sinus discharge and its gradual closure.

A chronic, long-standing sinus, even after radical surgery on the Primary tuberculosis focus, cannot heal on its own because it possesses a thick pyogenic membrane, is filled with granulation tissue, sequestra, and scars, and continues to produce pus. To close such a sinus, its course and possible branching must first be clarified using contrast fistulography, followed by fistulonecrectomy with excision of the sinus tract.

When the sinus is located close to the primary bone tuberculosis focus—which occurs in tuberculous coxitis or other joint affections—radical removal of the pyogenic membrane throughout its entire length does not present major difficulties. It is important to operate carefully, using anatomically sound approaches.

Surgical excision of the migration abscess tracts in tuberculous spondylitis is more challenging. Depending on the direction of its extension, as determined by fistulography, an extraperitoneal lumbar approach is performed. However, to make the tract more visible, a dye (such as a 1 % methylene blue solution with hydrogen peroxide) is injected through the sinus prior to surgery.

Sometimes it is not possible to completely remove the pyogenic membrane along its entire length, and the surgeon must be content with a shortening fistulonecrectomy. Such an operation, combined with continuous antibacterial therapy, can lead to the patient's recovery.