Tuberculosis of the entheses

Abstract

Purpose: Tuberculosis of the osteoarticular system usually manifests as joint arthritis. There is no available English literature on the tubercular involvement of the enthesis (tendon-bone junction).

Methods: We performed a retrospective analysis on 14 patients with tuberculosis of the tendon-bone junction. Patients presenting with a sinus with or without presence of radiological evidence of bone destruction around the enthesis, and pain unresponsive to a trial of analgesics and physical therapy, were evaluated by closed or open biopsy for tuberculosis. A staging system is proposed for biopsy-proven tuberculosis of the enthesis.

Results: Between 2006 and 2010, we treated 14 patients with tuberculosis of the tendon-bone junction. Biopsy-proven cases of tuberculosis of the enthesis were administered anti-tubercular drugs for a period of one year. Sequestrectomy was performed in advanced lesions. The tendon-bone junction was rested until the features of its healing were clinically evident. The patients aged between 18 and 52 years were followed up for an average of 1.7 years after cessation of anti-tubercular drug therapy. They responded favourably, and none had recurrence of the disease.

Conclusions: This study describes the tubercular involvement of the entheses, which heretofore has not been described in the literature. The rarity of its occurrence and lack of suspicion of an infectious aetiology in these locations frequently results in late diagnosis and incorrect initial treatment. This study also supports the "microtrauma theory" in the genesis of osteoarticular tuberculosis.

Fig. 1

Radiographs showing stage 2 tubercular lesion at the junction of the tibial tuberosity with the ligamentum patellae

Fig. 2

Stage 3 tubercular entheso-osteomyelitis at the tibial tuberosity. The cloaca at the junction of the tibial tuberosity to the patellar tendon can be noted, and a faintly delineable sequestrum can be seen in the metaphyseal area

Fig. 3

a Plain radiographs of the left hemipelvis showing stage 3 tubercular lesion of the iliac crest. Note that the sequestrum is not apparent on the plain film. b CT scan of the pelvis showing tubercular sequestrum in the left iliac crest with an abscess noted in the gluteal muscles

Fig. 4

a Stage 2 tubercular entheso-osteitis of the acromion process of the scapula, with subluxation at the acromioclavicular joint. b Radiographic evidence of healing of tuberculosis at the junction of the deltoid attachment to the acromion, noticeable by the appearance of sclerosis around its margins

Fig. 5

a Plain anteroposterior radiographs of the proximal tibia showing presence of lucencies in the proximal tibia. A metaphyseal sequestrum can be poorly delineated. b CT scan of the proximal left tibia shows a well-defined sequestrum in the metaphyseal region, underlying the attachment of the patellar tendon. The sequestrum has a thin cortical shell over its lateral aspect. The lateral paratendinous approach was used for sequestrectomy