Arthroscopic management for early-stage tuberculosis of the ankle
Due to atypical clinical presentation, wide use of antibiotics, and lack of specificity in diagnosis, diagnosis of tubercular (TB) infection in joints is increasingly difficult, and misdiagnosis is common. The use of arthroscopy for the diagnosis and treatment of early-stage ankle TB has rarely been reported. This case series intended to present the clinical outcomes of arthroscopic management for early-stage ankle TB.
Fifteen patients with chronic synovitis of the ankle and suspicious cause of early-stage ankle TB underwent arthroscopic treatment from April 1, 2010, to March 31, 2016. These cases all failed to confirm diagnosis of TB by ankle arthrocentesis. They included seven males and eight females with an average age of 37.5 (8 to 70) in the study. Among them, five cases had history of pulmonary tuberculosis, and six had history of trauma. The procedure included synovial membrane biopsy and debridement. The diagnosis was confirmed by pathologic examination and culture. The treatment was combined with systemic anti-tuberculous drugs. Follow-up measurements included VAS score, AOFAS score, ESR, CRP, and MRI.
After arthroscopic management, 13 cases confirmed TB by pathologic examination and culture, and two cases still remained clinically suspected TB; the rate of confirmed case was 87%. The incision healed well in all cases, and no serious complications were observed. There were significant differences in VAS scores, AOFAS scores, ESR, and CRP between before and after treatment (P < 0.01). Joint swelling disappeared or was relieved after 2 months in most patients. Ankle swelling and pain in one patient was improved after changing anti-tuberculous drugs. MRI suggested that all patients had effusion in the articular cavity, accompanied by bone edema of the distal tibia and talus before the treatment. After the surgery, the effusion was significantly reduced, and the signal of bone edema almost disappeared. No recurrent TB was found during the follow-ups.
Arthroscopic management for early-stage ankle TB is minimally invasive, safe, and reliable. It can easily obtain samples from specific area of TB for further confirmation of the diagnosis, while the debridement can also assist in local disease control. For cases of highly suspicious joint TB, arthroscopic biopsy and debridement after transient anti-TB treatment is recommended.
Level of evidence
Level IV, therapeutic case series
KeywordsAnkle Tuberculosis Arthroscopy Treatment
American Orthopedic Foot and Ankle Society
Erythrocyte sedimentation rate
Human leukocyte antigen
Magnetic resonance imaging
Visual analogue scale
World Health Organization
According to WHO’s 2014 estimation, about 9.6 million people in the world were infected with tuberculosis (TB), resulting in 1.5 million deaths, which made TB the primary cause of infectious diseases . In 2015, the annual incidence of tuberculosis in China was 68/100,000. Joint TB accounts for about 3% of the extrapulmonary TB. Occasionally, there would be cases of ankle TB [2, 3, 4, 5]. China has shown a high incidence of TB [1, 6], and the problem is becoming even more severe with the emergence of multidrug-resistant TB in recent years . Sinus tract is often concomitant in ankle TB, which would severely affect the motor function of the ankle. The diagnosis of tuberculous infection in a joint is difficult, and misdiagnosis is common due to its atypical clinical presentation, wide use of antibiotics, and lack of specificity in diagnosis.
A few decades ago, ankle arthroscopy was considered unavailable because the joint spaces were too narrow to operate. But in the recent 20 years, it has made astounding advances and been successfully used for osteochondral lesions of the talus, impingement syndrome, ankle arthrodesis, etc. [8, 9, 10, 11, 12, 13, 14, 15, 16, 17]. However, there are very few reports on ankle TB treatment [2, 8, 9, 10, 11, 12], and arthroscopic management for early-stage ankle TB is even less reported.
The main manifestation of early-stage ankle TB is chronic synovitis. Even though ankle arthrocentesis, bacterial culture, and pathological examination have been performed, it is still difficult to confirm the diagnosis. The authors have been using arthroscopy in treating ankle TB for some years and have achieved satisfying results. In order to further improve the level of diagnosis and treatment, we have followed the clinical outcomes after arthroscopic management for early-stage ankle TB and reported as follows.
The inclusion criteria were as follows: (1) patients with chronic ankle synovitis, where inflammatory and traumatic origins have been ruled out, and a strong TB suspicion was present but no infectious origin could be determined; and (2) patients who were able to take oral anti-TB drugs on schedule. The exclusion criteria were as follows: (1) patients who had been diagnosed with ankle TB, preferred conservative treatment, and did not need to obtain samples via arthroscopy; (2) patients who had sinus, sequestrum, and bone destruction; other surgical procedures were often necessary in addition to debridement; (3) patients who had unstable vital signs and were unsuitable for surgery; (4) patients who had low compliance of anti-TB drugs; and (5) patients who had active pulmonary TB, which was contagious and should be transferred to a specialist hospital.
General data of patients
Patients (n = 15)
History of pulmonary tuberculosis (n, %)
History of trauma (n, %)
Time from symptom to surgery (months)
Surgical purpose and technique
The purposes of the surgery included two aspects: (1) for the suspected cases, to directly observe the lesion under arthroscope and to make relevant examinations with the focal tissue (pathological examination, L-J medium culture, TB-PCR) for further confirmation, as well as to improve the treatment plan with more accurate judgments on the prognosis; (2) arthroscopic debridement, i.e., direct removal of necrotic tissue, which could improve the effective concentration of anti-TB drugs in the focal tissue and be an adjunct to local disease control. During the surgery, if the area of articular cartilage damage is less than 2 cm2 and the residual cartilage is stable, it is often effective to perform debridement rather than arthrodesis.
Epidural anesthesia or nerve block anesthesia was applied. Patients were placed in supine position, buttocks padded high, and the ankle was maintained in the neutral position. Marker pen was used to mark the superficial peroneal nerve and dorsalis pedis artery. Pneumatic tourniquet was applied with the pressure of 250–300 mmHg. The non-invasive ankle traction was used with the posterior malleolus hanging, which was easy for debridement . Ankle arthrocentesis was performed to drain the joint effusion, and sample of the joint effusion was obtained for acid-fast staining test; saline 10–20 mL was injected into the articular cavity. After incision, a 30° ankle arthroscope (2.7 mm in diameter, Smith & Nephew Endoscopy, Andover, MA) was used. Ankle exploration was carefully performed through the anteromedial incision between the anterior tibialis tendon and the medial malleolus ; further exploration was conducted through the anterolateral incision at the lateral of the peroneus tertius tendon under arthroscope. In general, synovial fluid that is purulent and turbid could be seen under arthroscope, and sometimes fibrous protein and necrotic tissue, hyperplasia of synovial tissue, congestion, and pale areas could also be seen. The diversity of the cartilage damage could be manifested as cartilage degeneration, defects, layering, and subchondral bone exposure. Next, typical pathological tissue and necrotic tissue were taken under the arthroscope as samples for pathological examination, Lowenstein-Jensen medium culture, TB-PCR, etc. Shaver, basket forceps, pituitary rongeur, and other instruments were used to completely remove the necrotic tissue and degenerative synovia of the articular cavity. A drainage tube was placed to infuse 0.1 g isoniazid into the joint cavity and then clamped. The negative pressure drainage could be started 12 h after surgery. The incision was closed with 3-0 sutures. After surgery, all patients were given plaster casts to keep the ankle in the functional position.
Postoperative management for ankle TB is very important. Patients with fever or pain should receive symptomatic treatment. The volume of the negative pressure drainage must be observed carefully, and drain removal is usually performed 24–48 h after surgery. In addition, patients are encouraged to have high-protein diet to improve nutrition. It is an important principle to reduce the movement of ankle joint or to conduct moderate exercise without ankle pain. Weight-bearing exercise could be done 2 weeks postoperatively when the sutures are taken out. Postoperative anti-TB drugs are also very important, with the principles of combined, standardized, adequate, and full course. The quadruple therapy of isoniazid, rifampicin, pyrazinamide, and ethambutol was continued for 3 months, triple therapy of ibuprofen, rifampicin, and pyrazinamide for another 3 months, and then the combination of isoniazid and rifampicin; the total oral administration of anti-TB drugs lasted up to 18 months. The patients could walk with gradual weight-bearing after the sutures were taken out 2 weeks after surgery.
Follow-up and statistical analysis
The patients were followed up at postoperative 2 and 6 weeks and 3, 6, 12, 18, and 24 months. The symptom changes and the laboratory tests such as ESR, CRP, blood routine, liver and kidney function were re-checked. VAS and AOFAS scores were checked at the last follow-up. The cure criteria were as follows: after 3 months of drug discontinuance, patients could be discharged when they could walk painlessly for 1 km and ESR was normal for more than 3 months postoperatively. The enumeration data was expressed with mean ± standard deviation; statistical analysis was conducted by paired t test with SPSS 16.0; P < 0.05 indicated statistical significance.
Comparison of results before treatment and at the last follow-up
7.1 ± 2.2
38 ± 12
57 ± 24
28 ± 12
At the last follow-up
1.0 ± 0.5
85 ± 7
15 ± 4
5 ± 2
P < 0.01
P < 0.01
P < 0.01
P < 0.01
In one case, the symptoms were not significantly improved 3 months postoperatively. After consulting with pharmacologists, anti-TB drugs were adjusted and the patient was cured in later follow-ups. We chose three typical cases as follows.
Video S1. Ankle arthroscopy to debride tuberculous infection. (MP4 2170 kb)
Video S2. Claudication gait before surgery. (WMV 19928 kb)
Video S3. Gait is normal 5?years postoperatively. (WMV 21347 kb)
Tuberculosis, which is mainly found in developing countries, still remains as a major global health problem for 20 years since WHO announced it a global public health issue [1, 2, 20]. In 2010, China published an official guideline for the diagnosis and treatment of pulmonary TB. However, there are no guidelines for joint TB, whose treatment is still referred to guidelines for pulmonary TB . Due to its atypical symptoms, joint TB is often neglected and misdiagnosed [21, 22, 23]. According to references [9, 24, 25, 26], some patients were given open surgery while receiving anti-TB drugs, but this method would be more traumatic and cause difficulty in postoperative incision healing. Arthroscopy has made great progress in many countries. Yet arthroscopy for ankle TB is still rarely reported, and the effectiveness and safety of the technique is unclear.
Early diagnosis and treatment of joint TB has a decisive significance on the prognosis [2, 27, 28, 29, 30, 31, 32, 33]. MRI examination is helpful in the early diagnosis of ankle TB . It can show clear vision of effusion in the articular cavity and sometimes with low-signal focal tissue, and high signal of edema is seen in the distal tibia and the talus (kissing sign). Under MRI, the signal dispersion range of TB is usually greater than osteoarthritis. It is often confined to the lateral of the tibiotalar joint rather than bilateral, which is seen in the case of tumor or early bone necrosis. It is also easy to observe the soft tissue abscess near the ankle and even in the subtalar joint by MRI. Due to its non-invasiveness and sensitiveness, MRI is used as a routine examination of ankle TB. Arthroscopy is of great diagnostic value for cases that cannot be confirmed by ankle arthrocentesis. Through this minimally invasive surgery, typical lesion samples can be obtained for pathological examination, and the positive rate was higher than that by arthrocentesis; besides, the sample volume obtained by arthroscopy was also more, which was very useful for bacterial culture and other related examinations. Arthroscopy can also timely correct misdiagnosed cases, such as in our case 3. Cases that cannot be confirmed before surgery are often quite intractable. In this study, the rate of confirmed cases after arthroscopy is 87%, which we believe is very impressive.
Arthroscopy could not only provide samples for pathological examination and L-J medium culture to confirm the diagnosis, but also be an adjunct to local disease control. The purposes of surgical treatment are first, to further confirm the diagnosis, especially for early joint TB; and second, the removal of necrotic tissue, fibrous protein, and hyperplasia of synovial tissue, which would be conducive to reducing the inflammatory response [35, 36, 37]. When the TB gradually stabilizes, the debridement of hypertrophic scarring tissue could further improve the ankle function. There are only a small number of follow-up cases reported for the surgical technique of ankle TB [38, 39, 40, 41, 42, 43, 44, 45, 46]. Due to the lack of large sample studies, it is difficult to decide the optimal surgical approach. Traditionally, the surgical treatment for advanced active joint TB includes debridement, arthrodesis, and arthroplasty combined with a certain period of anti-TB therapy . Of course, intraoperative exploration of articular cartilage damage is the most reliable evidence for determining which surgical procedure to perform. Small area of cartilage damage, especially when the residual cartilage is stable, such as in our case 1, could consider using the arthroscopic debridement to retain ankle function; results show that the patient’s prognosis is satisfactory. In large areas of cartilage damage, such as in our case 3, arthroscopic debridement and effective anti-TB drugs will be enough for children to achieve satisfactory prognosis; ankle arthrodesis is not necessary.
Ankle TB is very rare and published data of arthroscopic management for it is rather limited. This study also has some limitations, such as small sample size and relatively short follow-up period. At the same time, due to limited number of cases, it is difficult to conduct comparative studies between arthroscopy and pure drug therapy. Thus, the therapeutic value of arthroscopy is also difficult to determine. Future multi-center controlled studies are expected to address these limitations.
Arthroscopic management for ankle TB is minimally invasive, safe, and reliable. It can easily obtain samples for further confirmation, and the removal of lesions may be an adjunct to local disease control. Arthroscopy can also help evaluating cartilage damage, providing prognostic information of ankle joint function. During the surgery, if the area of articular cartilage damage is less than 2 cm2 and the residual cartilage is stable, it is often effective to perform debridement rather than arthrodesis.
We would like to thank Xin Chen from the Centre for Joint Surgery, Southwest Hospital, Third Military Medical University for the language support for this article.
This work was financially supported by the Natural Science Foundation Project of CQ CSTC (no. CSTC, 2016shmszx0630).
Availability of data and materials
The datasets analyzed during the current study are available from the corresponding author on reasonable request.
LY enrolled the patients in the study and participated in the interpretation of the data. XD is the lead surgeon of the study that he conceived and designed and participated in the drafting and editing of the manuscript. Both authors read and approved the final manuscript.
Ethics approval and consent to participate
This study was approved by the Ethics Committee of the Southwest Hospital, Third Military Medical University (Army Medical University); all patients had signed the informed consent and agreed to participate in the follow-up.
Consent for publication
Informed consent was obtained from all individual participants included in the study.
The authors declare that they have no competing interests.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
- 20.Chen L, Pang Y, Ma L, Yang H, Ru H, Yang X, Yan S, Jia M, Xu L. First insight into the molecular epidemiology of Mycobacterium tuberculosis isolates from the minority enclaves of southwestern China. Biomed Res Int. 2017;2017:2505172. https://doi.org/10.1155/2017/2505172. CrossRefPubMedPubMedCentralGoogle Scholar
- 22.Arathi N, Ahmad F, Huda N. Osteoarticular tuberculosis-a three years' retrospective study. J Clin Diagn Res. 2013;7(10):2189–92.Google Scholar
- 32.Johansen IS, Nielsen SL, Hove M, Kehrer M, Shakar S, Wøyen AV, Andersen PH, Bjerrum S, Wejse C, Andersen ÅB. Characteristics and clinical outcome of bone and joint tuberculosis from 1994 to 2011: a retrospective register-based study in Denmark. Clin Infect Dis. 2015;61(4):554–62.CrossRefGoogle Scholar
- 41.Inoue S, Matsumoto S, Iwamatsu Y, Satomura M. Ankle tuberculosis: a report of four cases in a Japanese hospital. J Orthop Sci 2004;9(4):392–398. 41.Google Scholar
- 42.Li JH, Zhang ZH, Shi T, et al. Surgical treatment of lumbosacral tuberculosis by one-stage debridement and anterior instrumentation with allograft through an extraperitoneal anterior approach. J Orethop Surg Res 2015;10:62.Google Scholar
- 43.Wu P, Luo C, Pang X, Xu Z, Zeng H, Wang X. Surgical treatment of thoracic spinal tuberculosis with adjacent segments lesion via one-stage transpedicular debridement, posterior instrumentation and combined interbody and posterior fusion, a clinical study. Arch Orthop Trauma Surg. 2013;133(10):1341–50.CrossRefGoogle Scholar
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.