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PURPOSE OF THE STUDY: Tuberculosis (TB) in a joint region presents high risk of damage to the joint. Consequences of a late diagnosis and inadequate therapy may be serious particularly in the large joints of lower extremities. Tuberculosis of knee and hip joints accounts for about 25% to 35% of osteoarticular tuberculosis (OAT). The aim of this study was to evaluate the objective and subjective results of tuberculosis treatment in knee and hip joints. MATERIAL AND METHODS: Of 258 OAT patients treated at the Specialised Treatment Centre Jevícko between January 2005 and September 2012, tuberculosis of the hip joint was diagnosed in 31 patients in whom three hips were treated by incision and drainage and 10 by total hip replacement; 18 patients had tuberculosis of the knee joint with the following treatment: puncture in seven knees, incision and drainage in eight, excochleation of a tuberculous focus in the proximal tibia in two, removal of a bursa in one, arthrodesis in four and total knee replacement in four patients. The patients continued to be followed up at the Jevícko Centre. The scale of 1 to 5 (best to worst) was established for evaluation of objective and subjective results of the treatment. The data were analysed using the basic statistical characteristics and compared. RESULTS: The objective evaluation was better for the hip joint; the sums of relative frequencies of marks 1 to 3 were 72.22% in the knee and 80.65% in the hip. In the knee more than 50% of the cases fell in the interval <1.304; 4.252>, in the hip this was <1.296; 3.672>. The hip joint was better subjectively evaluated, it had a higher sum of relative frequencies of marks 1 to 3, i.e., 96.77% as compared with 88.89% for the knee. In the knee more than 50% of the cases had marks in the interval <0.767; 3.122>; in the hip this was <0.869; 2.680>. The hip joint was better evaluated both objectively and subjectively. DISCUSSION: An early diagnosis allows for the treatment of synovitis, which has a better prognosis than an arthritic disease. The subjective perception of treatment results showed a better evaluation than its objective correlate. Many patients were satisfied with the results, even with an immobilised joint (in arthrodesis). Total joint replacement in OAT patients does not always provide expected results in either knee or hip joints. Arthrodesis also has its indications related to health condition, age and social status of the patient. In periprosthetic TB infections, a careful consideration should be given to removal of the prosthesis and its re-implantation in relation to all circumstances associated with each particular case. CONCLUSIONS: Tuberculosis of large weight-bearing joints is a rare entity in the countries with low TB prevalence, including the Czech Republic. It is necessary to pay attention to diagnosis and therapy and make them more effective even at higher costs associated with total hip replacement in TB or post-TB patients in order to maintain or restore joint function. At the time of borders open for citizens from countries with higher TB prevalence, the diagnosis of OAT should be considered.

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PURPOSE OF THE STUDY: Tuberculous hip arthritis accounts for about 15 % of all orthopaedic forms of tuberculosis and ranks third after spinal and knee joint tuberculosis. The aim of this study was to present the results of total hip arthroplasty (THA) for treatment of post-infectious arthritis or ankylosis, or previous arthrodesis. MATERIAL: A group of patients, 16 women and 10 men, treated at the 1st Department of Orthopaedics, 1st Faculty of Medicine, Charles University in Prague, between 1980 and 2007, was evaluated. All patients had tuberculous hip arthritis in their history and subsequently underwent THA. The average age at the time of THA was 65 years. METHODS: Indications for THA following tuberculous coxitis were secondary post-infectious arthritis in 20 patient, ankylosis (fibrous or osseous) in four and conversion from arthrodesis in two. Intra-operative samples were taken for microbiological examination, polymerase chain reaction (PCR) and histological examination. Anti-tuberculous drugs (rifampicin and isoniazid) and cephalosporin were administered intra-operatively following the sample collection and continued post-operatively. Cephalosporin was discontinued on post-operative day 11, rifampicin and isoniazid were administered for further 3 to 5 months with regular laboratory tests. RESULTS: The average post-operative values for flexion ranged from 0 to 90 degrees, for abduction from 0 to 35 degrees and for both internal and external rotation from 0 to 30 degrees. At the end of treatment all patients walked without aid and with full weight-bearing on the operated leg. No complications were recorded. Intra-operative findings of microbiological, PCR and histological examinations were negative. No recurrent tuberculous disease was found. DISCUSSION: A total joint replacement in any post-infectious condition is a complex issue. The average time between achieving a steady state o tuberculous arthritis and the THA procedure was approximately seven years. The outcome was evaluated as good by 75 % of the patients, who would be willing to undergo the surgery again. The clinical picture and radiographic and laboratory findings were within norms at regular follow-ups, which is in agreement with the literature data. Our system of intra- and post-operative administration of anti-tuberculous drugs and antibiotics proved very efficient. CONCLUSIONS: In contrast to arthrodesis or Girdlestone resection arthroplasty, THA results in a marked improvement of painless joint motion. Before any patient is indicated for THA, a thorough medical history with laboratory, internal and pulmonary (including heart and lung radiographs) examination is necessary. When there is more than one tuberculous disease in the patient's medical history, other organ systems such as urinary or reproductive tracts should also be examined. In addition to conventional radiography, examination by computed tomography or magnetic resonance imaging is indicated. The priority is an individual approach of the phthisiology orthopaedist to the indications ensuing from this comprehensive examination, with assessment of both physical and psychic state of the patient in view of post-operative rehabilitation.

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Tuberculous hip arthritis ranks third in the classification of orthopedic tuberculosis, after tuberculosis of the spine and knee joint. It accounts for about 15 % of all orthopedic tuberculosis. The aim of this paper is to demonstrate the etiology, clinical presentation and forms of disease on the case reports of six patients. The scope of disease is wide - from a mild reversible synovial form, then fibrous or bone ankylosis, to severe destruction of the hip with subluxation or dislocation, pseudoarthrosis or chronic arthritis with a fistula. The wide diversity of clinical findings and difficulties is making diagnosis are often responsible for a late start of therapy. However, only an early and adequate treatment permits the prevention of irreversible damage to the hip joint or further complications. Key words: tuberculous hip arthritis.

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PURPOSE OF THE STUDY: Orthopedic tuberculosis is number one in non-pulmonary forms of tuberculosis and, among these, knee joint tuberculosis ranks second after spinal tuberculosis. Arthritic lesions are currently treated by total knee arthroplasty (TKA). MATERIAL: A group of 10 patients who, after having gone through tuberculous gonarthritis, underwent TKA was evaluated for the period from 1980 to 2005. It consisted of six women and four men, whose average age at the time of arthroplasty was 65 years. METHODS: The most frequent indication for TKA after tuberculous gonarthritis was post-inflammatory arthritis (80 %); the other indication was fibrous ankylosis (20 %). No conversion of arthrodesis to total replacement was carried in our group. All patients underwent pre-operative microbiological tests including PCR, as well as histological examination. Pre- and post-operative prophylaxis included anti-tuberculous (AT) drugs (rifampicin and izoniazid) combined with a cephalosporin antibiotic. AT drugs were administered for 3 to 5 months after surgery in accordance with the results of laboratory tests. RESULTS: In 1980 to 2005, ten patients after tuberculous gonarthrosis underwent TKA at our department. No complications were recorded. The average range of flexion was 0 to 90 degrees. None of the patients needed any walking aid, and all were able of full weight-bearing on the treated limb. There was no recurrent tuberculosis in this group. DISCUSSION: Any implantation of an endoprosthesis in a post-inflammatory terrain is always difficult. Subjective evaluation by the patients was good. At long-term follow-up, clinical, radiographic and laboratory findings were within standards, which is in agreement with the results of other authors. The pre- and post-operative therapy with AT drugs and antibiotics was used in all patients. CONCLUSIONS: Compared to arthrodesis, TKA brings about a significant improvement in the patient's mobility as well as a better quality of life. Before the patient is indicated for TKA, emphasis is placed on recording a thorough medical history, complete laboratory examination, radiography, CT scans, or magnetic resonance imaging, relevant orthopedic, internal and pulmonary examination including X-ray of the heart and lungs, as well as the assessment of the patient's somatic and psychical state with regard to the post-operative rehabilitation course.

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This paper presents current methods used in the diagnosis of osteoarticular tuberculosis in the Czech Republic. It draws attention to difficulties and errors associated with the diagnosis of this disease. The aim of this study is to provide a comprehensive review of relevant diagnostic methods, from medical history to imaging techniques. A misdiagnosis and/or a late establishment of the diagnosis, which may result in inadequate primary therapy, prolong both the time needed for complete treatment and the duration of absenteeism. These may eventually have negative economic and social implications.

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The authors deal with a rare case of a 14-year actinomycotic affection of the left lower limb in at present 39 years old female patient. They point out the difficulty and mistakes in the diagnosis of the mentioned disease. During the 14 years the patient was hospitalized, examined and treated at approximately 6-7 clinics all over the republic with different conclusions within the differential diagnosis. It is a fact that the history of the patient was underestimated, not all possibilities of the examination within differential diagnosis were used and at one clinic the histological finding got even lost, the examination was not repeated and the treatment focussed only on the incipient symptoms of the disease. Therefore in the first stage of the disease the diagnostic conclusion was synovialitis of the left ankle, in the following years the tuberculous etiology was suspected and finally the disease was diagnosed as a juvenile rheumatoid progressive ostearthritis with negative rheumatotests. Proper diagnosis was determined only after 13 years (bacteriological tests revealed actinomycotic particles on the dorsum of the left foot, chronic liver lesion and incomplete nephrotic syndrome were diagnosed. However, it has to be taken into account that in the 14-year course of the disease there were several-year periods without subjective complaints and with a complete normalization of the clinical condition. As stated in the discussion it is a rare case of the disease, we have not found in the available literature any similar case study of actinomycotic affection. Key words: actinomycosis of the musculoskeletal apparatus.

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