Knee tuberculosis
Introduction
Introduction to knee joint tuberculosis Knee tuberculosis is a secondary lesion like other bone and joint tuberculosis. The vast majority of tuberculosis is transformed. In the case of large-scale tuberculosis cases in China, the incidence of knee joint tuberculosis is second only to spinal tuberculosis. The joint ranks first. Foreign literature reports that the incidence of knee joint tuberculosis is also behind the spine, ranking first or second in the six major joints. Knee tuberculosis is more common in children under 10 years of age. There is no significant difference in gender. Children's knee joint tuberculosis Due to the long course of disease, it is easy to get involved in the epiphysis, so it often causes developmental malformation of the affected limb. Knee joint tuberculosis usually occurs unilaterally, and cases of bilateral tuberculosis are rare. Usually divided into simple synovial tuberculosis, simple bone tuberculosis and total joint tuberculosis. basic knowledge The proportion of the disease: the probability of the population is 0.08%, more common in patients with tuberculosis Susceptible people: no specific population Mode of infection: non-infectious Complications: anemia
Cause
Knee joint tuberculosis
(1) Causes of the disease
The knee joint is the largest flexion joint of the whole body. Its joint surface is composed of hemisphere and platform. It is incompatible, unstable, and easy to damage. The knee joint is located at the midpoint of the weight of the lower limb. The leverage of the joint is very strong. Large, so the knee joint is prone to strain and sprain, resulting in joint hematoma synovial damage. In addition, the knee joint is the joint with the most synovial membrane, rich in peripheral vascular network, slow blood flow, and tuberculosis is easy to grow here. .
Human tuberculosis is caused by human and bovine Mycobacterium tuberculosis. It generally does not directly invade bones and joints. Instead, it is transferred from the lungs to the bones and joints. The tuberculosis grows slowly. It reaches the bone and joint tissues with the blood. In the absence of a suitable growth environment, it can be lurking for a long time. Once the body's resistance and immunity decline, the tuberculosis bacteria will multiply, and the quantity and virulence will increase greatly, leading to disease.
In summary, the occurrence of tuberculosis is not only related to the number and virulence of tuberculosis, but also closely related to the anatomical mechanical characteristics of the knee joint itself and the resistance of the body. The changes of these factors may be the cause of the onset of knee joint tuberculosis. .
(two) pathogenesis
The disease is a series of pathological processes mainly caused by Mycobacterium tuberculosis on the synovial membrane, bone and cartilage infection and destruction of the knee joint. The disease is mainly secondary infection, and is often secondary to tuberculosis, but most patients have lung lesions. Absorption, fibrosis or calcification, the primary lesions are usually formed in childhood, and the tuberculosis that enters the bloodstream through the primary lesion forms a large number of bacterial emboli. These emboli are transported by blood to various tissues of the body, most of which are Eliminated by the body's immune system, a small number of undestroyed Mycobacterium tuberculosis multiply under favorable conditions, forming some tiny lesions, surrounded by fibrous tissue, in a static state, with the increase of age, the body's immunity is reduced or other disadvantages Under the influence of factors, the latent tubercle bacilli rapidly multiply, break through the fibrous tissue, and the inflammation expands or invades new areas, producing local symptoms and systemic reactions.
The knee joint is the joint with the most synovial membrane in the whole body joint, while the tuberculosis mainly invades the synovial membrane or the bone end, so the incidence of synovial tuberculosis in the knee joint is the most, followed by simple bone tuberculosis and total joint tuberculosis.
Bone tuberculosis occurs in the lower part of the femur or the metaphysis and the upper and lower sides of the humerus. It is divided into two types: central type and marginal type. The central type of lesion is often prone to dead bone. After the bone is absorbed, the cavity is formed. In the trunk, the dead bone is less common. When the simple bone tuberculosis penetrates the cartilage into the joint and involves the synovial membrane, it becomes the whole joint tuberculosis. The edge type disease located near the joint is easy to invade the joint, causing the whole joint tuberculosis and the humeral head. Tuberculosis and tibial tuberosity tuberculosis are rare, and tibial tuberculosis is rare. It is also divided into two types: central type and marginal type. Generally, sacral tuberculosis easily breaks through the joint surface and causes total joint tuberculosis.
Knee synovial tuberculosis is initially characterized by inflammation, synovial congestion, edema, serous exudation, gradual turbidity, and late synovial hyperplasia, which can be divided into two types: localized and diffuse. Clinically, the former is rare. Simple development of synovial tuberculosis can involve cartilage and subchondral bone plate tissue. At this time, the destruction of cartilage and subchondral bone plate is still limited to the edge. Most of the articular surface cartilage remains intact. At this time, it is early total joint tuberculosis. If the lesion is controlled and stops developing at this time, part of the joint function can be preserved. The destruction of the late total joint tuberculosis is not limited to the destruction of the cartilage and subchondral bone at the edge, and most of the articular cartilage and bone destruction continue to increase, half a month. The plate and anterior cruciate ligament will also be affected. The posterior cruciate ligament is sometimes spared from the synovial membrane. Due to the massive destruction of cartilage and bone, the joint capsule and lateral collateral ligament are relaxed, and the hamstring and tendon bundles are pulled. Lower, the humerus can be dislocated to the posterolateral side. When the humeral tuberosity or the anterior aspect of the humerus is destroyed, it can cause knee reversal, but it is less common, such as childhood femur and Destruction of the epiphyseal plate at the upper end of the bone may lead to growth and development disorders of the affected limb, resulting in shortening or excessive length of the limb. If the tuberculosis of the knee joint is not controlled early, it may be prone to cold abscess rupture in the later stage, and may cause secondary mixing. Infection, the sinus tract is not cured for a long time, causing a lot of scars and fibrosis. The knee joint is fibrotic or ossified. At this time, the joint often has flexion and internal and external valgus deformities, especially the abductor flexor subluxation of the humerus or The occurrence of total dislocation gives the patient a lifelong pain.
Prevention
Knee joint tuberculosis prevention
The disease is a local manifestation of systemic tuberculosis lesions, with high cases and second place in joints and extremities of the extremities. Therefore, it is necessary to actively treat the symptoms, improve the function of the knee joints of patients, and actively treat the primary disease of tuberculosis. Active treatment of primary tuberculosis is the key to the prevention and treatment of this disease.
Complication
Knee joint tuberculosis complications Complications anemia
In the late stage, due to joint lumps, bone destruction and toughness often loosening, de-bone can be dislocated to the posterior semi-dislocation, and knee valgus deformity can occur. Osteophyte destruction can cause limb shortening deformity. If the treatment is not timely and incomplete, the late stage can develop. For total joint tuberculosis, extensive bone destruction, multiple cavities, narrow or absent joint space, extensive adhesions in the joints, scarring of the synovial membrane, etc., seriously affect the function of the knee joint, resulting in a large loss of labor.
Symptom
Knee joint tuberculosis symptoms Common symptoms Low heat fatigue, loss of appetite, lymph node enlargement, lymph node tuberculosis, night sweat, joint effusion, joint deformity, muscle atrophy
1. General clinical manifestations
Most patients with knee joint tuberculosis are young and young, mostly with unilateral joints. Patients with double joints or multiple joints are rare. Patients usually have a history of tuberculosis or tuberculosis, and a small number of patients can have other bone tuberculosis or bone. External tuberculosis.
Usually the knee joint patients have mild systemic symptoms. If there are other active tuberculosis in the whole body, the symptoms can be aggravated. The systemic symptoms can be characterized by low fever, night sweats, anemia, weight loss, fatigue, loss of appetite and accelerated erythrocyte sedimentation rate. After the nighttime self-loss of the protection of the diseased joints, the sudden activation of the activity caused by nightingales, easy to cry and other special performance.
2. Symptoms and signs
(1) Pain and tenderness: Simple synovial tuberculosis generally has less pain and is characterized by dull pain; fatigue is increased, rest is light, and tenderness is more common and not limited during examination.
Simple bone tuberculosis also shows mild knee pain, but local tenderness is obvious and limited, which is different from simple synovial tuberculosis.
Total joint tuberculosis occurs after the abscess of simple synovial tuberculosis and simple bone tuberculosis enters the joint cavity. At this time, a large amount of tuberculosis substance pours into the joint cavity, which can cause acute congestion and swelling of the synovial membrane, so the pain can be aggravated. Sometimes it can cause severe pain, especially when the activity is heavy, the knees are extensively tender, and the children are nightingale.
When the above three types of knee joint tuberculous abscesses are decompressed and the lesions are absorbed, the pain may gradually or even disappear.
(2) Swelling: simple synovial tuberculosis shows that the joint is generally swollen, but because it is tuberculous swelling, it reflects the red, heat inflammation is not, so there is a "white swelling", when the joint fluid is more than the time can be detected The floating sputum test is positive, but the late synovial tuberculosis is mainly hypertrophic hyperplasia. At this time, when the knee joint is examined, the feeling of the face can be found under the hand. The floating sputum test can be false positive. This is the clinically common knee joint tuberculosis. The feeling of "face".
The swelling of simple bone tuberculosis is often limited to one side, that is, on the side of the corresponding lesion, in the case of simple bone tuberculosis, the joint exudate is generally less, the swelling is not as obvious as the synovial tuberculosis, and the floating sputum test is often negative.
The swelling of the whole joint tuberculosis is obvious and extensive. When the joint is examined, the swelling is a hard skin-like feeling. When the exudate is small and the synovial membrane is hyperplasia, edema, and hypertrophy, it can also touch the facial or rubbery feeling.
(3) Muscle atrophy: Because of the limited function of knee joint synovial tuberculosis, the quadriceps muscle atrophy is due to the atrophy of the upper and lower muscles of the knee joint and the joint itself is swollen, forming a fusiform joint.
Simple bone tuberculosis generally has less limited knee function in the early stage, so its muscle atrophy is also lighter.
Total joint tuberculosis is a typical shuttle-shaped deformity due to obvious obstacles in knee joint function, obvious muscle atrophy, and swelling of the knee.
(4) dysfunction: a simple synovial tuberculosis patient may have mild lameness, knee extension is limited, and the degree of dysfunction is related to the severity of the lesion.
Simple bone tuberculosis is mainly caused by soreness and discomfort after exertion, but the function is not obvious, so it is not obvious.
Knee joint function of patients with total joint tuberculosis will be significantly restricted, often unable to walk, need to support crutches or bedridden, knee bone destruction and muscle atrophy and protective spasm, etc., often cause pathological subluxation of the knee joint, so After the illness is cured, lameness and deformity are also left behind.
(5) abscess and sinus simple knee joint synovial tuberculosis such as abscess is a cold abscess, this time may be a localized bulge, more common in the armpit, around the knee joint and around the calf, its abscess often formed after ulceration The sinus does not heal for a long time, and it can also form a mixed infection, and the pus smells bad.
Simple bone tuberculosis in the bone lesions to form a sinus tract is relatively rare, such as the formation of cold abscess rupture, the sinus long-term unhealed, there may be dead bone fragments through the sinus ostium, bone hardening, can also lead to mixing infection.
Total joint tuberculosis in the armpit is a cold abscess that can be touched around the knee joint. It forms a chronic sinus after rupture, and it will not heal for many years. It can excrete rice soup through the sinus, cheese-like substance and dead bone, sinus The skin around the crossing is scarred and the skin is pigmented.
(6) Malformation: knee joint deformity caused by simple synovial tuberculosis and simple bone tuberculosis is often not obvious, mainly mild flexion deformity, knee joint overextension is limited, general joint function is not limited, with the lesion The functional malformation caused by healing is correctable.
Total joint tuberculosis patients with severe bone destruction, combined with muscle atrophy, muscle spasm and ligament relaxation, can produce knee internal and external valgus deformity and subluxation, when severe, the joint deformity is strong, resulting in the affected limb hip joint can not Straightening and heel contraction, the affected limb presents a deformity of the hip, knee and foot, and can only land on the toe.
(7) Lymph nodes: The lymph nodes of the femoral triangle caused by the knee joint are rare. If there is swollen lymph node in the triangle, it will help the diagnosis of knee joint tuberculosis, and lymph node tuberculosis can form abscess ulceration.
Examine
Knee joint tuberculosis examination
X-ray examination is often used for the auxiliary examination of this disease. In recent years, MRI examination is used for some cases that are difficult to diagnose:-
1, X-ray inspection:
X-ray examination showed that osteoporosis and soft tissue swelling appeared at the beginning of simple synovial tuberculosis, and the transparent shadow of the underarm fat pad disappeared. The elderly with the disease course also showed that the bone was damaged by erosion. In the simple bone tuberculosis, the central type showed bone vagueness. It is a frosted glass-like type, which can form dead bones and cavities in the future. The marginal type can be seen that the bones at the edge of the bone are damaged by erosion. In the whole joint tuberculosis, the bones are extensively loose and decalcified, and the degree of bone damage is classified and destroyed. The joint space is narrowed or disappeared. When the ring is severely broken, the posterior semi-dislocation of the humerus can be seen. Sometimes the knee valgus is deformed, the external rotation is deformed, and the sinus can not be cured for a long time.
2. MRI examination:
MRI can directly and clearly show various normal structures and pathological changes in the joints. It has high resolution for various soft tissues and has superiority that other imaging techniques cannot match. MRI can show articular cartilage destruction and show good bone defects. In the knee of the patient, the typical joint tuberculosis osteoporosis-like changes can be seen, and the cartilage is exfoliated in large areas. The knee joint tuberculosis mostly progresses from synovial tuberculosis, layer-by-layer erosion of cartilage, subchondral bone and bone, in joint tuberculosis. MRI has a high diagnostic accuracy for meniscus and cruciate ligament lesions. However, due to the influence of proliferative synovial membrane, the meniscus II to III signal and partial fracture of the cruciate ligament are unclear and should be carefully distinguished.
MRI can show the extent and extent of tuberculosis lesions in the knee: for the early exudation-based lesions, it is mostly characterized by total joint effusion, synovial hyperplasia is relatively light, and meniscus, ligament, cartilage and bone are not obviously damaged. The joint cavity can be injected with anti-tuberculosis drugs; for the diffuse hyperplasia of the synovial membrane, the MRI signal is mixed and irregular irregular low-signal strips, protruding nodules or clumps and no obvious damage to the bone.
3, arthroscopy
Arthroscopic examination is of unique value for early diagnosis of synovial tuberculosis of the knee. Biopsy tissue and glioma resection can be performed at the same time.
4, ESR is significantly increased, white blood cells are also slightly higher.
Diagnosis
Diagnosis and diagnosis of knee joint tuberculosis
diagnosis
Diagnosis should be based on the patient's history of tuberculosis exposure or infection, patient's age, clinical manifestations, body temperature, erythrocyte sedimentation rate, X-ray examination, timely biopsy if necessary, animal vaccination to determine the diagnosis, attention to early diagnosis, and sometimes lymphadenopathy Large, with tuberculosis, biopsy has a certain significance for the diagnosis of knee joint tuberculosis, should be distinguished from traumatic, suppurative and rheumatoid arthritis.
Differential diagnosis
It is difficult to diagnose the early diagnosis of the disease. It is difficult to find clear symptoms and signs and physical and chemical indicators to make a clear diagnosis. Pay attention to the diseases that are confused with the disease and pay attention to the differential diagnosis. The diseases that need to be identified include the following:
1. Rheumatoid arthritis often begins in the unilateral knee joint, so it is not easy to distinguish from simple synovial tuberculosis, can be through rheumatoid factor, tuberculin test, joint fluid tuberculosis smear microscopy or joint fluid tuberculosis Culture and synovial biopsy to confirm the diagnosis.
2. Traumatic synovitis usually has a clear history of trauma, more young and young, no systemic tuberculosis symptoms, characterized by local joint swelling and effusion, joint puncture fluid can be light yellow clear or blood color, X-ray film without bone changes .
3. Hyperplastic degenerative arthritis is mainly caused by the onset of the elderly. Joint pain is characterized by pain after rest and pain after walking. It often has a popliteal cyst. The size of the cyst often changes with the severity of joint pain. Resting for a period of time, cyst Often reduced or disappeared, the pumping is the same as ordinary joint fluid, no signs of rapid sedimentation and bone destruction.
4. Pigmented villonodular synovitis This disease is a tumor-like disease, divided into two types of villi and nodules, with multiple knee and ankle joints. The medical history can last for several years to several decades, and the joints are swollen. It can have a "dough" or nodular sensation, joint function is generally unaffected, erythrocyte sedimentation is not fast, long-term cases can have small bone-disintegration at the edge of bone, and joint puncture can extract dark blood or coffee-like liquid, pathological biopsy Can be diagnosed.
5. Hemophilic arthritis is more common in boys, often with a family history of maternal, usually patients with bleeding tendency, recurrent joint effusion, joint drainage is bloody, X-ray film shows subperiosteal hematoma calcification, joint space stenosis The joint surface is irregular, especially characterized by the deepening and widening of the femoral condyle.
6. Shake's joint disease This disease is secondary to neurological diseases. The joint itself loses painful self-protection and causes trauma. It is also called neurological joint disease, which is characterized by severe joint destruction, joint swelling and bleeding. The joint surface is broken and the joint function is not limited and the local pain is not or very slight. In some patients, the abnormal activity of the joint is also increased, and the neurological examination shows that the deep feeling of the affected limb is weakened or disappeared.
7. Acute infection of septic arthritis is easy to identify, and it is difficult to identify chronic infection. Chronic infection often occurs after purulent infection in other parts of the body, so it is often necessary to perform bacteriological examination of joint puncture fluid.
8. Bone abscess This disease is a low-toxic localized bone infection with slow onset, dull pain, and increased after exertion. It occurs in the lower part of the femur and in the upper metatarsal area of the tibia. X-ray films show local osteolytic destruction and peripheral bone sclerosis. There is a periosteal reaction and new bone formation, which can be confirmed by pathology and bacteriology.
9. Tumor synovial sarcoma has severe pain and rapid progress. The synovial mass is a large lobular shape, which can be calcified, which can erode and destroy the epiphysis. Synovial chondromatosis can be seen as swelling of the synovial membrane. Nodules, X-ray films show many free bodies or calcifications in the joint cavity, and other tumors that occur at the upper end of the tibia of the femur are: giant cell tumor of the bone, osteosarcoma, fibrosarcoma, Ewing's tumor and reticuloma. Etc. Generally, identification is not difficult.
