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5.3. The management of Chronic Osteomyelitis and Septic Arthritis (continue)

5.3.2. ‘Chronic’ tuberculous bone and joint infections

These usually arise insidiously (less so with HIV/Aids) and biopsy may be necessary to establish a definite diagnosis. They may mimic other conditions and yet again diagnosis may demand a high level of suspicion and ‘thinking of the possibility’. ‘Common things commonly occur’ and tuberculosis remains a great scourge in the developing world.

The mainstay of management once the diagnosis has been confirmed is an appropriate course of anti-tuberculous chemotherapy preferably given under close supervision. This is best arranged by our specialist medical colleagues.

Orthopaedic surgery does have a role to play, but this is virtually always secondary to chemotherapy. Early joint disease without bone or joint destruction can do well with drug treatment, and traction will often allow an early tuberculous knee to regain useful movement.

Occasionally sequestrectomy and debridement are called for, but cold abscesses usually disappear with appropriate chemotherapy, while incision and drainage or even aspiration run the risk of introducing troublesome secondary infection. Very destroyed joints may have to be arthrodesed (knee) or excised (hip). It is wise to perform these procedures under chemotherapy cover.

Tuberculous infection of the spine with or without neurological involvement is a huge subject in itself, and outside the remit of these Guidelines.

5.3.3. Chemotherapy as an aid to diagnosis

A therapeutic trial with anti-tuberculous drugs will occasionally be helpful in supporting a suspicion of the presence of a tuberculous infection. However, in the developing world we do see a number of patients who have received a six month course of these drugs for a condition which does not turn out to be, and probably never was a tuberculous infection.

5.3.4. Fungal infections of bones and joints

Classical madura foot, (and occasionally this infection in other bones and joints) presents in some areas of the world.

A madura foot, with multiple sinuses overlying considerable swelling	A Madura Arm	A Madura Knee

The history is long, the foot and ankle painful and swollen, and there will be multiple sinuses discharging pus in which granules of fungus can occasionally be seen. Radiography will usually clinch the diagnosis with destruction of bones and joints, and a suspicion of spicules of new bone formation. Biopsy and microscopy will confirm the diagnosis.

The X-ray appearance of a madura foot bone destruction and new bone formation with a suggestion of 'spicules'	X-ray of a madura arm

An X-ray of a madura foot - bone destruction and new bone formation with a suspicion of spicules.

Secondary infection is common and may explain the transient improvement seen with antibiotic therapy. Until recently there have not been any specific drugs which will kill the Madura fungus, and amputation (with delayed primary or secondary closure) was often required, when the patient’s general condition allowed. However, when offered the choice of amputation or continuing to walk on a chronically infected foot some patients prefer to keep their diseased limb, and this may give good service for a surprising length of time. Recently we were delighted to hear that specific anti-fungal drugs have been developed which appear to be able to control if not irradicate these tedious chronic infections.

Actinomycosis also may attack bones and joints, and although we have no personal experience of this disease we suspect that amputation (when possible and accepted) will be the only possible treatment. (But see para above).