Orthopaedic Surgery (2010), Volume 2, No.

1, 5863

SURGICAL TECHNIQUE

Arthroscopically assisted treatment of adolescent knee

joint tuberculosis os4_59 58..63

Lin Guo MD, Liu Yang MD, Xiao-jun Duan MD, Guang-xing Chen MD, Ying Zhang MD,
Gang Dai MD
Center for Joint Surgery, Southwest Hospital, The Third Military Medical University, Chongqing, China

Objective: To evaluate the role of knee arthroscopy in diagnosis and treatment of knee joint synovitis and total joint
tuberculosis (TB) of adolescence.
Methods: Forty-one patients with knee TB, aged 716 years, were treated using knee arthroscopy from June 2002 to
December 2006. Clinical data were reviewed at followed up and evaluated using the Lysholm score.
Results: Among the 41 patients, 36 were diagnosed as having TB on the basis of preoperative clinical manifestations
and laboratory results, and the remaining 5 as synovitis preoperatively, TB being confirmed postoperatively by arthros-
copy and pathological examination. Specimens from 37 patients were confirmed as tuberculosis by pathological exami-
nation, while the other 4 were reported as chronic synovitis and necrotic tissue. Patients were followed-up for 658
months postoperatively (average, 43.5 months). All patients were treated with knee arthroscopy surgery and postopera-
tive medication and no relapses occurred over the duration of follow-up. The mean Lysholm score was 91.4 points. The
range of movement of the knee joint in 6 patients remained at 70110. Two patients retained an extension lag of 10
and 25, respectively.
Conclusion: Diagnosis and treatment of adolescent TB is different from that of other TB patients. Arthroscopically
assisted treatment of adolescent knee joint TB has the advantages of early diagnosis, minimization of trauma, thorough
clearance and rapid recovery. Early treatment with arthroscopically assisted debridement, early rehabilitation and
postoperative medication can preserve maximal function of knee joint and avoid arthrodesis. This is an ideal method for
the treatment of adolescent knee TB.
Key words: Knee; Arthroscopy; Adolescent; Tuberculosis, osteoarticular

Introduction to this problem. Both the typical manifestations under

arthroscopy and the specimens obtained by arthroscopic
Since the introduction of antituberculosis drugs, the
biopsy can result in an accurate diagnosis of early or
morbidity of tuberculosis (TB) has been greatly reduced.
atypical TB.
However, there is a tendency towards an increase in the
Another reason for surgical treatment is to preserve knee
morbidity of TB in particular subpopulations, such as the
function by early intervention. For adolescent patients,
adolescent1,2. The clinical symptoms and results of labo-
treating TB by conservative treatment alone can take a long
ratory tests may be obscure and difficult to evaluate3,4.
time and be relatively ineffective. The necessarily pro-
Drug-resistance and less virulent strains of the TB bacillus
longed duration of treatment can cause a decreased range
compound the difficulties of correctly interpreting the
of momovement (ROM) in the knee joint, capsular adher-
clinical symptoms and results of laboratory tests. These
ence and degeneration of cartilage. If surgical debridement
combined factors make the early diagnosis of TB difficult.
is introduced too late under these circumstances, there will
Arthroscopy-assisted debridement can provide a solution
be some residual malfunction in the affected knee. In
recent years, the importance of early diagnosis and medi-
Address for correspondence Liu Yang, MD, Center for Joint cation therapy combined with selective early surgical inter-
Surgery, Southwest Hospital, The Third Military Medical University,
vention have been recognized as important principles for
Chongqing, China 400038 Tel: 0086-023-68765280; Fax: 0086-
023-65464006; Email: guolin6212@163.com treatment5,6. In this paper we will introduce the surgical
Received 2 September 2009; accepted 19 September 2009 technique of arthroscopy-assisted debridement for treat-
DOI: 10.1111/j.1757-7861.2009.00059.x ment of the TB-affected knee joint in adolescent patients.

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Orthopaedic Surgery (2010), Volume 2, No. 1, 5863 59

Figure 1. MRI revealing the pie-like TB synovitis sign in the supra-

patellar bursa. Figure 2. Tongue-like TB synovitis in posterior cavity.

Materials and methods

Arthroscopic manifestations of knee joint TB include:
Patient data (i) turbidity of joint fluid visible as soon as the arthro-
From June 2002 to December 2006, 41 cases of adoles- scope is introduced into the joint; (ii) the synovium shows
cent knee TB, including 13 male and 28 female patients, tongue-like (Fig. 2) or finger-like (Fig. 3) proliferation;
were treated by arthroscopy. The age range was 716 years (iii) the synovium is thick, delicate, pale and swollen; (iv)
(average, 12.5 years). All patients had a history of 314 no synovial congestion can be seen as in septic arthritis,
months (average, 4.8 months) of swelling, pain and dys- once the poorly vascularized superficial layer has been
function of the affected knee. peeled back, the more congested capsule or deeper layer of
synovium becomes visible; (v) in some cases pathological
Diagnosis of TB caseation can be seen under the synovium; (vi) typical
Diagnostic criteria were as follows: (i) afternoon hectic loose fat bodies can be seen in some cases (Fig. 4); (vii) in
fever and night sweats; (ii) repeated swelling of the knee late stage TB, spontaneous peeling off of the cartilage
joint; (iii) previously diagnosed or currently active pul- can be seen and there may be pathological caseation
monary TB (iv) Erythrocyte sedimentation rate (ESR) beneath it.
over 40 mm/h; (v) positive result of DNA sequencing of
the TB bacillus or the staining test for acid-fast bacilli; (vi)
positive result of the purified protein derivative test; (vii) Preoperative medication
positive result of blood TB antibody test; (viii) typical All patients should take antituberculosis medication for
roentgenographic evidence of bony erosion at the edges of at least 2 weeks preoperatively to prevent the spread of TB
the femur and tibia combined with osteopenia; (ix) the as a result of surgical intervention. Medications include
split pie sign on magnetic resonance imaging (MRI) isoniazid (6 mgkg-1d-1), rifampin (9 mgkg-1d-1), etham-
indicating severe synovial proliferation of the suprapatel- butol (15 mgkg-1d-1), and streptomycin (15 mgkg-1d-1).
lar bursa (Fig. 1), sometimes with a visible cartilage lesion;
(x) previous intra-articular synovial biopsy resulting in a
diagnosis of TB; (xi) cachexia and depression; (xii) diag-
nostic treatment with antitubercular drugs resulting in
resolution of the pathology in the knee.
Patients with any two of the above criteria combined
with essential clinical manifestations should be suspected
as having TB. When other causes for chronic arthritis have
been excluded, antituberculosis medication should be
used even in the absence of pathological confirmation.
For patients in whom the diagnosis of TB is suspected,
arthroscopy-assisted biopsy and debridement should be
performed. Because the arthroscopic manifestations of TB
can be very characteristic, arthroscopy can play an impor-
tant role in TB diagnosis. Figure 3. Typical finger-like TB synovitis.

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60 L Guo et al., Arthroscopy and treatment of knee joint TB

Figure 4. Liposome of TB synovitis.

Figure 5. Blunt excision of layered synovium can avoid excessive
trauma.

Once the ESR has decreased to 40 mm/h or there is an

obvious trend towards improvement, the patient can be explore and debride the posterior compartment through
prepared for surgery. the posterolateral and posteromedial portals. Thorough
irrigation is used to clean the posterior compartment. If
Surgical technique necessary, posteromedial and posterolateral approaches
Epidural or nerve block anesthesia of the femoral nerve should be made. The 30 arthroscope should be placed in
and lumbar plexus can be used for surgery. Patients who the intercondylar notch to view the lateral compartment.
are younger than 12 years should receive general anesthe- Then a percutaneous needle is passed through the transil-
sia. The patient is placed in a supine position. A tourni-
quet should always be used, but without exsanguination
of the lower limb, in order to prevent the spread of infec-
tion. The pressure of tourniquet should be set at
120 mm Hg higher than systolic blood pressure. 7 mm 30
and 70 arthroscopes are used for better exploration of the
whole capsular cavity. The debridement procedure should
vary according to the different types of knee joint TB.

Synovial tuberculosis
For this stage of TB, synovial proliferation and articular
hydrops are the dominating intra-articular pathology.
There are no cartilage lesions or loose bodies. Since the
clinical symptoms are usually atypical at this stage, the
Figure 6. A shaver was used to clear un-layered synovium.
purpose of surgical intervention is to confirm the diagno-
sis. Thus the purposes of surgical treatment include evalu-
ation of the pathological stage, estimation of prognosis
with therapy, accurate biopsy and excision of excessively
proliferated synovium. Anteromedial and anterolateral
portals are used for a thorough exploration. Biopsy is
taken under direct monitoring. The suprapatellar syn-
ovium is suitable for biopsy; a whole layer of synovium
should be taken for pathological examination. Necrotic
tissue and excessively proliferated synovium should be
removed. During this procedure, a snipper and suction
could be used to remove these tissues (Fig. 5) and a shaver
should be used as little as possible (Fig. 6) in order to
preserve the intactness and blood supply of the synovium
(Fig. 7). In general, for this stage there is no need to Figure 7. Appearance of synovium and capsule after debridement.

2010 Tianjin Hospital and Blackwell Publishing Asia Pty Ltd

Orthopaedic Surgery (2010), Volume 2, No. 1, 5863 61

luminated skin and into the posterolateral compartment. mycin, intramuscular streptomycin and orally adminis-
Then the skin is cut superficially with a scalpel and an trated ethambutol are used for at least 4 weeks. Then the
approach made with forceps. The posteromedial approach prescription is changed to oral administration for at least
is performed in the same way. For thorough debridement, 812 months.
a trans-septal approach should be made to facilitate better A rehabilitation protocol should be instituted on the
exploration. first postoperative day. Early training in flexion and exten-
sion with adequate pain control can help the patient to
Late stage TB recover to a full ROM. A modest protocol of 35 flexion
The process of synovial proliferation has slowed down. circles every two hours during the day is enough. A long
Usually the patient has a limited ROM and extension lag. leg brace is used to prevent extension lag during the night.
Adhesions, caseation, necrotic tissue and cartilage lesions Weight bearing should be limited during the first 4 weeks
are the main pathology to be dealt with. These should be after surgery.
thoroughly debrided to shorten the course of disease and Another important aspect of therapy is nutrition and
preserve maximal knee joint function. Any detached car- supportive treatment. TB patients are usually cachectic
tilage edges should be shaved off until the remaining car- and depressed during the whole course of the disease.
tilage is stable. This is called chondroplasty. Adhesions in Traditional Chinese herbs can be used to increase the
the suprapatellar compartment and intercondylar space appetite and digestive function. Patient with anaemia and
should be released to increase the flexion angle. Manipu- hypoproteinemia should be treated with blood and
lation can be used to get a full ROM if necessary. Exten- plasma transfusion if necessary. Surgeons should encour-
sion lag must be corrected at the same time. Posterolateral, age the patient to take an active attitude during the dura-
posteromedial and trans-septal approaches are performed tion of therapy.
to clean the posterior compartment. Liver and renal function should be checked every
month. The ESR should be tested every month until the
TB complicated by sinus formation result is negative.
The affected limb should be carefully prepared before
surgery, especially at the sinus site. Intra-articular debri- Follow-up
dement is done as performed for synovial TB. The inner All cases were re-evaluated as to whether there was
ostium should be debrided under arthroscopic vision. If recurrence of TB. ROM, quadriceps strength and the
the sinus is short, the outer ostium should be excised Lysholm scale were evaluated during the follow-up
and closed. If the sinus is long or passes through bone, period5.
the sinus wall should be debrided with a shaver. Strep-
tomycin is introduced into the sinus and the outer
Results
ostium closed.
Of the 41 patients with TB of the knee, 30 had synovial
Postoperative medication and rehabilitation TB, 3 were complicated by sinus formation, 5 had early
A drainage tube is put inside the cavity and left there for stage total joint involvement, and 3 late stage total joint
24 h postoperatively. The drainage tube should be involvement. The diagnosis of TB was confirmed by
directed outside the cavity superiorly to the patella in pathological examination in 37 cases. The other 4 cases
order to avoid formation of a new sinus through thinner were reported as chronic synovitis and necrotic tissue, but
soft tissue. Three hundred mg of isoniazid, 1 g of strepto- achieved complete relief after being treated with anti-TB
mycin, 20 mg of ropivacaine and 0.3 mg of epinephrine drugs. The postoperative hospitalization time ranged
are combined in 20 ml and injected into the joint cavity, from 4 to 14 days (average, 8 days). There were no cases of
where they should remain for at least 12 h before applying delayed healing of incision or spread of TB. In those with
suction to the drainage tube. Pain should be controlled sinuses, the sinuses healed after using streptomycin
with appropriate analgesia in patients who had a limited locally. Three cases had swelling of the knee and were
ROM preoperatively. Streptomycin should be put on inci- treated with intra-articular streptomycin and isoniazid.
sions and in sinuses if any effusion is noted when chang- The patients were followed up for 658 months (average,
ing the dressings. If there is recurrence of knee joint 43.5 months) and there were instances of recurrence of
swelling, the synovial fluid should be aspirated with a TB. The Lysholm score ranged from 75 to 98 points
syringe. One gram of streptomycin and 300 mg of iso- (average, 91.4). In 39 patients (95.1%) the strength of the
niazid should be injected into the joint after aspiration quadriceps was over grade IV. Twenty-six patients (63.4%)
each time it is performed. Intravenous isoniazid and rifa- had no obvious atrophy of the quadriceps. Thirty-five

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62 L Guo et al., Arthroscopy and treatment of knee joint TB

patients (85.4%) achieved a ROM of over 120 (average, Value of arthroscopy in the treatment of TB
137.2). There was no extension lag in these patients. Four
patients with synovial TB and two with total joint involve-
Confirmation of the diagnosis
In some TB cases, a diagnosis based on laboratory tests
ment had obvious dysfunction of the knee joint with a
and clinical symptoms can be elusive. The accuracy of
ROM between 70 and 110, including two cases of exten-
pathological examination relies on both the quality of the
sion lag (10 and 25).
biopsy and the experience of the pathologist. Arthroscopy
can help to make the diagnosis of TB by allowing direct
visualization of its typical manifestations and providing
Discussion the capacity to select sites for biopsy under direct moni-
toring. Usually the pathological result becomes available
Diagnosis of adolescent knee joint TB
by the fourth or fifth day postoperatively. Until then, the
The morbidity of adolescent TB has increased greatly
surgeon needs to make a clinical diagnosis and prescribe
in south-west China in recent years. The symptoms of
postoperative treatment on the basis of the arthroscopic
adolescent TB are not particularly characteristic4.
manifestations. Manifestations such as synovial prolifera-
Routine clinical examination and investigations are rela-
tion with a poor blood supply and loose fat bodies are
tively ineffective in differentiating TB of the knee from
typical, and can be used to exclude acute arthritis of the
rheumatoid arthritis, pigmented villonodular synovitis,
knee. Since rheumatoid arthritis and chronic septic arthri-
chronic septic arthritis, and non-specific arthritis. There-
tis have similar manifestations, laboratory tests are needed
fore clinical symptoms such as loss of weight, low fever,
to discriminate them from TB prior to surgery6. However
and night sweats, and investigations demonstrating pul-
pathological examination result is still the gold standard
monary TB, an increase in ESR and a positive purified
for the definitive diagnosis of TB.
protein derivative skin test become important diagnostic
proofs. X-ray films show obvious bone destruction and
osteoporosis in cases of total joint TB, but only minor Facilitation of rehabilitation
soft tissue swelling and osteoporosis in cases of synovial For most late stage TB patients, a limited ROM of the
TB. An MRI T2 sequence shows a suprapatellar split pie knee joint is one of the chief complaints. Release from
sign which is not easy to distinguish from that seen in within the joint cavity can always achieve a satisfactory
rheumatoid arthritis. TB polymerase chain reaction ROM during surgery. To maintain the good ROM post-
(PCR) examination of joint fluid can be more precise operatively, the concept of implementing a rehabilitation
but is less sensitive5. PCR examination of the synovium protocol early is well accepted7. Treating TB with long-
is more likely to be positive than PCR of the joint fluid. term medication only can unnecessarily prolong the dura-
While histological examination of synovial tissue is best tion of treatment when the diagnosis of TB has been
for the diagnosis of TB, it is invasive and takes more unclear. Treatment by aspiration of the joint and injection
time. A synovial sample taken from the wrong site can of anti-TB medication does not debride necrotic tissue
result in a false negative for TB. Taking the whole layer of and therefore treatment takes longer. Open surgery has
suprapatellar synovium increases the diagnostic rate. For limitations when cleaning the posterior cavity, with a
these reasons arthroscopy is valuable for the diagnosis, as resultant increase in the recurrence rate of TB8. Also it can
well as for the treatment, of TB of the knee. In our series adversely affect the ROM of the knee joint after surgery.
there were four patients who were diagnosed as having Arthroscope-assisted debridement has a well-deserved
TB by arthroscopy, but in whom TB was not confirmed reputation for minimal invasion4. Its advantage, especially
by histological examination. These four patients achieved considering that most TB cases are juveniles, is that the
complete relief after arthroscopic debridement and patients are likely to achieve complete rehabilitation after
anti-TB medication. In conclusion, the clinical symp- surgery. The rate of recurrence rate of knee joint dysfunc-
toms of adolescent TB are not so obvious. Histologic tion postoperatively can be reduced by arthroscopic
examination can also sometimes be unhelpful because release.
the specimen has been taken from the wrong site. The
authors believe that diagnosis of knee joint TB should be Shortening of the course of the disease
based on a typical arthroscopic appearance, a positive Timing of surgical intervention is important. Some-
response to anti-TB treatment, exclusion of other causes times, because of the slow progression of the disease, TB
of chronic synovitis, typical clinical symptoms, and posi- patients are likely to present for surgery too late to
tive results of investigations including histological salvage the function of knee joint. There are no definite
examination. rules about when arthroscopy should be introduced into

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Orthopaedic Surgery (2010), Volume 2, No. 1, 5863 63

the treatment of TB of the knee. Usually we make this The limitations of arthroscopy
judgment by evaluating the stage of disease pathology For the experienced surgeon, it is relatively easy to make
and the degree of impairment of knee joint function. For a clinical diagnosis of TB on the basis of the arthroscopic
adult patients, administration of antiTB medication for manifestations. But for the inexperienced surgeon, a
two months without any improvement in symptoms or biopsy should always be taken for a definite diagnosis. In
with progressive limitation of knee joint function could our experience, juvenile patients are not likely to complete
be indications for the intervention of arthroscopy. an early rehabilitation protocol even when surgical
Because juvenile patients are less likely to combat TB trauma has been kept to a minimum. Good pain control
infection and more likely to lose the ROM of their knee and progressive physical therapy are important to facili-
joints, early intervention is more imperative than in tate the restoration of knee joint function.
adult patients.
The purpose of debridement of the infected knee cavity
is to clear necrotic tissue, release adhesions, excise prolif-
erated synovium and improve the blood supply of the References
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