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Tuberculosis and other Unusual Infections


Tuberculosis

Tuberculosis is transmitted primarily through inhalation or ingestion of Mycobacterium tuberculosis or Mycobacterium bovis. After exposure, the infection may be cleared by the host, lead to a primary infection, or can later be reactivated from a latent infection. Thereafter, lymphogenous, hematogenous, or contiguous extension to other tissues and organ systems may occur. The clinical presentation depends on the presence of isolated musculoskeletal involvement or miliary disease. Miliary disease has a rapid course, and constitutional symptoms include fever, chills, and cough, with accompanying pleuritic pain, weight loss, and fatigue. The patient may have acute or chronic symptoms. The mortality rate for miliary disease is 20% to 30%. The term “miliary” refers to the chest radiograph appearance of tiny lesions (1 to 5 mm) scattered throughout the lung fields that resemble millet seeds.

Current estimates of the worldwide rate of tuberculosis infection are as high as one third of the world’s population. Even though the incidence of tuberculosis has been falling globally for several years, it remains one of the most frequent causes of death worldwide; the World Health Organization reported 1.1 million deaths in 2013. The highest rate of new cases is in Southeast Asia, but the highest rates of infection and mortality are in sub-Saharan Africa.

North American Demographics

According the Centers for Disease Control and Prevention (CDC), there were 9093 new cases of tuberculosis reported in the United States in 2017. Since 1992, there has been a 67% decrease in the rate of cases in the United States. There were 544 deaths in the United States attributed to tuberculosis in 2013, an 8% decrease from 2012. The provisional tuberculosis case count and incidence in 2017 were the lowest in the United States since surveillance began in 1953 at 2.8 cases per 100,000 population. Since 2014, the annual percentage rate has decreased 2.0% per year. However, to eliminate tuberculosis by 2100, the annual rate of decline should be 3.9%.

More than 80% of percent tuberculosis cases in the United States represent reactivation of latent tuberculosis infections rather than recent transmissions. There are older chemotherapeutic drugs, such as methotrexate, now used for various autoimmune diseases that can lower the immune system, leading to reactivation of latent tuberculous infection in an otherwise healthy patient.

Minozzi et al. reviewed 78 controlled trials involving 24,996 patients with rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis involving treatment with antitumor necrosis factor agents (adalimumab, golimumab, infliximab, certolizumab, and etanercept). Their meta-analysis showed increases in general infections (20%), serious infections (40%), and tuberculosis (250%).

In a systematic literature review by Cantini et al., it was found that non-antitumor necrosis factor agents used for the treatment of rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis had a negligible latent tuberculosis reactivation rate, raising the question as to the need for pre-treatment screening.

Populations most at risk include individuals with acquired immunodeficiency syndrome (AIDS) or other immunodeficiencies, patients with chronic renal failure, substance abusers, homeless or incarcerated individuals, and immigrants from developing countries. Foreign-born individuals account for approximately two thirds of recent tuberculosis cases in the United States. The high-risk period for developing the disease is within the first 5 years of immigration. Population density continues to be a risk factor; 75% of newly reported cases occur in metropolitan areas with a population of more than 500,000. In 2016, 1.0% of culture-confirmed cases were multidrug-resistant; 80.4% of those were primary tuberculosis cases, and 92% were in non-US-born persons.

Musculoskeletal Involvement

Tuberculosis commonly affects the pulmonary system but can affect virtually any organ system of the body. Skeletal tuberculosis accounts for 10% to 20% of cases of tuberculosis. Approximately 50% of patients with osseous tuberculosis have pulmonary involvement, and 30% to 50% of patients with osseous disease have vertebral involvement, most often in the lower thoracic spine. Frequently, a primary extraosseous lesion is not well delineated. Less frequently observed appendicular involvement usually affects major weight-bearing joints of the lower extremity, most commonly the hip and knee, followed in frequency by the foot, elbow, and hand. Virtually any other bone or joint can be involved. Soft-tissue abscesses with sinus tracks have been described, as has tenosynovitis.

The spine is the most common (30% to 50%) site of osseous involvement, especially in elderly individuals; however, spinal involvement is also common in children and in young adults from developing countries. A primary accompanying lesion may be discovered from the pulmonary or urogenital system or from an unknown source. Lymphogenous and hematogenous spread have been implicated in thoracolumbar lesions but less often in cervical or sacral lesions. Usually, active spinal lesions involve a particular segment: two vertebral bodies and the corresponding disc. Some authors have speculated that these areas are affected most often because of the generous arterial and venous supply and the high oxygen pressure requirement of the tuberculosis bacilli. A peridiscal presentation occurs in approximately 80% of patients, with the anterior vertebral body affected and contiguous progression through subligamentous burrowing (anterior longitudinal ligament) and eventual extension to the adjacent vertebrae. Less frequently, lesions occur centrally in the vertebral body. These lesions are more difficult to diagnose and may mimic a tumor or contribute to significant spinal deformities. Patients may have intramedullary granulomas, arachnoiditis, segmental collapse with anterior wedging, and gibbus formation (Pott disease). The posterior elements of the spine are rarely the only sites affected. Perispinal abscesses with sinus extension to the skin may also arise and extend through tissue planes to reach intraperitoneal structures. They have been reported to occur as far distally as the popliteal fossa. Patients present with pain, weakness, and, in the late stages, paralysis. Operative treatment of Pott disease is found in Chapter 42 .

Appendicular joint involvement typically affects the major weight-bearing joints of the lower extremities. Lesions involve the articular cartilage, which eventually is separated by granulomatous tissue. The trabecular zones of the bone are affected, with subchondral involvement affecting the weight-bearing capability of the joint, which may progress to significant accelerated joint surface degeneration. Pathologic assessment reveals a central caseating lesion within necrotic tissue and multinucleated giant cells.

Other, less frequently involved joints include the ankle, foot, and upper extremity joints. Patients may present with a limp and a joint that is warm and swollen and has a decreased range of motion. Tuberculosis in a joint markedly decreases its functional use; even when adequately treated, the disease may reactivate in isolated regions. Peripheral joint involvement from tuberculosis can be confused with other rheumatologic conditions (e.g., gout and rheumatoid arthritis). Periprosthetic joint infections have also been reported after hip, knee, and wrist arthroplasty in patients without a history of tuberculosis, with a delay in diagnosis of approximately 4 months.

Laboratory Findings

Patients may have a normochromic or normocytic anemia, pancytopenia, or thrombocytopenia. Frequently, the white blood cell count is normal, and the sedimentation rate may be elevated or normal. The patient may have the syndrome of inappropriate antidiuretic hormone. Tuberculosis skin testing is usually effective in diagnosing this condition; however, false-negative rates can be 20% to 30%. Immunocompromised individuals frequently have an unreliable skin test result. The hallmark of the diagnosis is demonstration of the tuberculosis acid-fast bacilli from a tissue or fluid source. Bone cultures taken from disc involvement are positive in 60% to 80% of cases. Sputum and gastric cultures of patients with pulmonary involvement usually are positive in more than 50%. The clinical utility of newer T-cell-based assays to detect skeletal and other forms of extrapulmonary tuberculosis has been studied in large cohorts of patients, which, in general, have shown the same results as testing in patients with pulmonary tuberculosis: such assays lack sufficient sensitivity and specificity to rely on them singly in the absence of traditional diagnostic testing such as biopsy and culture and imaging studies.

Tang et al. reported that the T-cell-based interferon gamma release assay (IGRA[T-SPOT.TB]), when used along with the rifampin resistance fluorescence test, Xpert MTB/RIF assay, produced a combined sensitivity of 91.9%.

Transbronchial biopsy specimens in patients with pulmonary involvement are positive in 70% to 86% of patients. Pulmonary exudates may reveal predominantly lymphocytic exudate or polymorphonuclear leukocytes and have a low pH that is slightly-to-moderately acidic. Molecular subtyping has also been used to assess infection patterns and sensitivities to medications.

Imaging

Plain radiographs of involved joints assist in guiding treatment. When a joint is involved, synovial infiltration that affects the subarticular bone is usually present. Periarticular erosions observed radiographically have an almost lytic appearance and can mimic infection, noninfectious arthropathy, or malignancy. Periarticular bone mass is decreased and may mimic juvenile arthritis. Progression to fusion is rare but can occur. Characteristics of typical spinal involvement have been described previously. Anterior vertebral involvement occurs more commonly than central vertebral involvement. There is a relative sparing of the intervertebral disc space. Later stages include a focal segmental collapse with anterior wedging and gibbus formation, characteristic of Pott disease.

Other imaging studies include a bone scan or a gallium scan, which can detect 88% to 96% of osseous tuberculosis lesions. Such scans are quite sensitive but not particularly specific for tuberculosis. MRI and CT can provide more detail and delineate the disease in earlier phases and are helpful in defining soft-tissue abscesses. MRI findings are nonspecific for tuberculosis and may be consistent with osteomyelitis, tumor, osteonecrosis, or neuropathic joint. If tuberculosis is a consideration, tissue or bone biopsy is indicated. Calcifications (best seen on CT) within paraspinous abscesses indicate bone destruction and are characteristic of spinal tuberculosis. CT or ultrasound-guided fluoroscopy can assist in obtaining appropriate tissue or fluid samples for additional studies. Arthrography and other imaging studies for tendon sheaths have been described but are used less frequently.

Nonoperative Treatment of Appendicular Tuberculous Infections

The primary treatment objectives for tuberculosis of bone include halting the infection, limiting deformity, maintaining mobility, and reducing discomfort. A multidisciplinary approach with the assistance of infectious disease and pain management specialists is ideal. Other affiliated team members should include nurses, physical therapists, occupational therapists, and orthotists. Approximately 90% of patients can be treated conservatively with chemotherapy, relative rest, and guided remobilization. Adjunctive splinting (passive, dynamic, functional) and casting techniques are useful for marked or painful and progressive joint involvement. At times, destructive changes are markedly progressive and eventually may lead to fusion of the joint (e.g., elbow), so it is crucial to place the extremity in a position of function (elbow flexion 70 to 90 degrees) to obtain an optimal range for future functional use.

A judicious, well-guided chemotherapeutic approach to tuberculosis along with the assistance of an infectious disease specialist yields optimal results. The pharmacologic agents and duration of treatment depend on the patient’s age, dissemination of disease, and accompanying medical conditions (e.g., AIDS, chronic renal failure). Several agents interact with medications typically used for immunosuppressed individuals, especially patients infected with human immunodeficiency virus (HIV). In these patients, it may be necessary to adjust dosages and modify treatment regimens. Various combinations of medications are used to treat tuberculosis: first-line drugs include isoniazid, rifampin, ethambutol, and pyrazinamide ( Table 23.1 ). Drug-resistant tuberculosis may require fluoroquinolones and injectable medications such as amikacin, kanamycin, or capreomycin, which typically are used for 20 to 30 months. Some types of tuberculosis are developing resistance to these drugs. Several new drugs are in development to be used as an add-on therapy. Bedaquiline, delamanid, and PA-824 target pulmonary tuberculosis, whereas linezolid and sutezolid are antibiotics for extensively drug-resistant tuberculosis infection. The efficacy and safety of these drugs are still being established. Traditionally, 12- to 18-month courses of therapy have been advocated for musculoskeletal tuberculosis because of concerns about poor drug penetration into osseous and fibrous tissues; however, more recent studies have suggested that shorter courses of treatment (6 to 9 months) with regimens containing rifampin are as effective as longer courses of treatment without rifampin.

TABLE 23.1
Doses ∗ of Antituberculosis Drugs for Adults and Children †
From Nahid P, Dorman SE, Alipanah N, et al: Official American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America clinical practice guidelines: treatment of drug-susceptible tuberculosis, Clin Infect Dis 63(7):147, 2016.
Drug Preparation Population Daily Once-Weekly Twice-Weekly Thrice-Weekly
First-Line Drugs
Isoniazid Tablets (50 mg, 100 mg, 300 mg); elixir (50 mg/5 mL); aqueous solution (100 mg/mL) for intravenous or intramuscular injection. Note: Pyridoxine (vitamin B6), 25–50 mg/day, is given with INH to all persons at risk of neuropathy (e.g., pregnant women, breastfeeding infants; persons with HIV; patients with diabetes, alcoholism, malnutrition, or chronic renal failure; or patients with advanced age). For patients with peripheral neuropathy, experts recommend increasing pyridoxine dose to 100 mg/day. Adults 5 mg/kg (typically 300 mg) 15 mg/kg (typically 900 mg) 15 mg/kg (typically 900 mg) 15 mg/kg (typically 900 mg)
Children 10–15 mg/kg — 20–30 mg/kg — †
Rifampin Capsule (150 mg, 300 mg). Powder may be suspended for oral administration. Adults ‡ 10 mg/kg (typically 600 mg) — 10 mg/kg (typically 600 mg) 10 mg/kg (typically 600 mg)
Aqueous solution for intravenous injection Children 10–20 mg/kg 10–20 mg/kg — †
Rifabutin Capsule (150 mg) Adults § 5 mg/kg (typically 300 mg) — Not recommended Not recommended
Children Appropriate dosing for children is unknown. Estimated at 5/mg/kg.
Rifapentine Tablet (150 mg film coated) Adults 10 mg/kg ||
Children Active tuberculosis: for children ≥12 years of age, same dosing as for adults, administered once weekly, Rifapentine is not FDA-approved for the treatment of active tuberculosis in children <12 years of age
Pyrazinamide Tablet (500 mg scored) Adults 18.2–26.3 mg/kg based on weight — 36.4–52.6 mg/kg based on weight 27.3–39.5 mg/kg based on weight
Children 35 (30–40) mg/kg — 50 mg/kg — †
Ethambutol Tablet (100 mg; 400 mg) Adults 14.5–21.1 mg/kg based on weight — 36.4–52.6 mg/kg based on weight 21.8–31.6 mg/kg based on weight
Children 20 (15–25) mg/kg — 50 mg/kg — †
Second-Line Drugs
Cycloserine Capsule (250 mg) Adults ∗∗ 10–15 mg/kg total (usually 250–500 mg) once or twice daily There are inadequate data to support intermittent administration.
Children 15–20 mg/kg total (divided 1–2 times daily)
Ethionamide Tablet (250 mg) Adults †† 15–20 mg/kg total (usually 250–500 mg once or twice daily) There are inadequate data to support intermittent administration.
Children 15–20 mg/kg total (divided 1–2 times daily)
Streptomycin Aqueous solution (1 g vials) for IM or IV administration Adults 15 mg/kg daily. Some clinicians prefer 25 mg/kg 3 times weekly. Patients with decreased renal function may require the 15 mg/kg dose to be given only 3 times weekly to allow for drug clearance.
Children 15–20 mg/kg — 25–30 mg/kg ‡‡ —
Amikacin/kanamycin Aqueous solution (500 mg and 1 g vials) for IM or IV administration Adults 15 mg daily. Some clinicians prefer 25 mg/kg 3 times weekly. Patients with decreased renal function, including older patients, may require the 15 mg/kg dose to be given only 3 times weekly to allow for drug clearance.
Children 15–20 mg/kg — 25–30 mg/kg ‡‡ —
Capreomycin Aqueous solution (1 g vials) for IM or IV administration Adults 15 mg/kg daily. Some clinicians prefer 25 mg/kg 3 times weekly. Patients with decreased renal function, including older patients, may require the 15 mg/kg dose to be given 3 times weekly to allow for drug clearance.
Children 15–20 m/kg — 25–30 mg/kg ‡‡ —
Para-amino-salicylic acid Granules (4 g packets) can be mixed in and ingested with soft food (granules should not be chewed). Tablets (500 mg) are still available in some countries, but not in the United States. A solution for IV administration is available in Europe. Adults 8–12 g total (usually 4000 mg) 2–3 times daily There are inadequate data to support intermittent administration.
Children 200–300 mg/kg total (usually divided 100 mg/kg given 2–3 times daily)
Levofloxacin Tablets (250 mg, 500 mg, 750 mg); aqueous solution (500 mg vials) for IV injection Adults 500–1000 mg daily There are inadequate data to support intermittent administration.
Children The optimal dose is not known, but clinical data suggest 15–20 mg/kg.
Moxifloxacin Tablets (400 mg); aqueous solution (400 mg/250 mL) for IV injection Adults 400 mg daily There are inadequate data to support intermittent administration. §§
Children The optimal dose is not known. Some experts use 10 mg/kg daily dosing, though lack of formulations makes such titration challenging. Aiming for serum concentrations of 3–5 uL/mL 2 h post dose is proposed by experts as a reasonable target.

FDA , US Food and Drug Administration; HIV , human immunodeficiency virus; IM , intramuscular; INH , isoniazid; IV , intravenous.

∗ Dosing based on actual weight is acceptable in patients who are not obese. For obese patients (>20% above ideal body weight [IBW]), dosing based on IBW may be preferred for initial doses. Some clinicians prefer a modified IBW (IBW + [0.40 × (actual weight − IBW)]) as is done for initial aminoglycoside doses. Because tuberculosis drug dosing for obese patients has not been established, therapeutic drug monitoring may be considered for such patients.

† For purposes of this document, adult dosing begins at the age of 15 years or at a weight of greater than 40 kg in younger children. The optimal doses for thrice-weekly therapy in children and adolescents have not been established. Some experts use in adolescents the same doses as recommended for adults, and for younger children the same doses as recommended for twice weekly therapy.

‡ Higher doses of rifampin, currently as high as 35 mg/kg, are being studied in clinical trials.

§ Rifabutin dose may need to be adjusted when there is concomitant use of protease inhibitors or nonnucleoside reverse transcriptase inhibitors.

|| TBTC Study 22 used rifapentine (RPT) dosage of 10 mg/kg in the continuation phase of treatment for active disease. However, RIFAQUIN and PREVENT TB safely used higher dosages of RPT, administered once weekly. Daily doses of 1200 mg RPT are being studied in clinical trials for active tuberculosis disease.

As an approach to avoiding ethambutol (EMB) ocular toxicity, some clinicians use a 3-drug regimen (INH, rifampin, and pyrazinamide) in the initial 2 months of treatment for children who are HIV-uninfected, have no prior tuberculosis treatment history, are living in an area of low prevalence of drug-resistant tuberculosis, and have no exposure to an individual from an area of high prevalence of drug-resistant tuberculosis. However, because the prevalence of and risk for drug-resistant tuberculosis can be difficult to ascertain, the American Academy of Pediatrics and most experts include EMB as part of the intensive-phase regimen for children with tuberculosis.

∗∗ Clinicians experienced with using cycloserine suggest starting with 250 mg once daily and gradually increasing as tolerated. Serum concentrations often are useful in determining the appropriate dose for a given patient. Few patients tolerate 500 mg twice daily.

†† Ethionamide can be given at bedtime or with a main meal in an attempt to reduce nausea. Clinicians experienced with using ethionamide suggest starting with 250 mg once daily and gradually increasing as tolerated. Serum concentrations may be useful in determining the appropriate dose for a given patient. Few patients tolerate 500 mg twice daily.

‡‡ Modified from adult intermittent dose of 25 mg/kg, and accounting for larger total body water content and faster clearance of injectable drugs in most children. Dosing can be guided by serum concentrations.

§§ Rifaquin trial studied at 6-month regimen. Daily isoniazid was replaced by daily moxifloxacin 400 mg for the first 2 months followed by once-weekly doses of moxifloxacin 400 mg and RPT 1200 mg for the remaining 4 months. Two hundred twelve patients were studied (each dose of RPT was preceded by a meal of 2 hard-boiled eggs and bread). This regimen was shown to be noninferior to a standard daily administered 6-month regimen.

Because treatment for tuberculosis is frequently modified, readily available guidelines from the CDC should be consulted. Although primary and secondary resistance to multiple medications has been reported, especially in countries outside the United States, most are isolated cases. Generally, only a small percentage of new patients (<1%) are resistant to multiple chemotherapeutic agents.

Treatment should not be limited to the patient, but chemoprophylaxis should be considered in family members and other close contacts who have a positive tuberculosis skin test. Chemoprophylaxis is particularly important in individuals who are younger than 50 to 55 years of age. Older individuals may not tolerate some of the medications typically used for prophylaxis. Treatment for chemoprophylaxis may last 3 to 12 months, depending on the conversion of the tuberculosis skin test.

Patients may require analgesics for pain. In severe cases, a pain management specialist should be consulted. Although the use of systemic corticosteroids to reduce symptoms in severe cases has been described, their use may mask a septic joint, and intraarticular corticosteroid injections can accelerate the destructive articular changes.

Operative Treatment

Operations applicable to bone and joint tuberculosis include (1) arthrotomy, including biopsy, synovectomy, and curettage with bone grafting of articular erosions; (2) curettage and bone grafting of extraarticular skeletal lesions; (3) resection of joints; (4) resection of bones; (5) evacuation or excision of soft-tissue abscesses; (6) arthrodesis; and (7) amputation. Arthroscopic debridement of joint tuberculosis has been shown to be effective.

Most authorities agree that effective antibiotic therapy should be started before surgery for tuberculosis. Miliary dissemination of the disease has been reported when surgery was done without adequate chemotherapeutic coverage. Long duration multi-antibiotic release scaffolds are under development using methylmethacrylate and hydroxyapatite.

Foot

In tuberculosis of the foot ( Fig. 23.1 ), many bones may become involved, and a delay in diagnosis increases the risk of joint involvement. Operative indications include juxtaarticular focus or joint destruction. Bones with cystic changes typically respond better than rheumatologic-appearing joints. When present, isolated lesions usually involve the calcaneus or talus. When several bones are involved, especially in adults, amputation is the procedure of choice. Curettage is indicated for isolated lesions even when sinuses are present.

FIGURE 23.1, A and B, Anteroposterior and oblique radiographs of tuberculous lesion involving base of first metatarsal. Medial and lateral cortices are eroded. C, MR image shows circumferential destruction of base of first metatarsal with extension into soft tissues.

Curettage for Tuberculous Lesions in the Foot

Technique 23.1

  • ▪

    Make an incision directly over the lesion or directly through a sinus or abscess, if present.

  • ▪

    Remove all necrotic and scarred tissue but not uninvolved osteopenic bone.

  • ▪

    Pack the cavity with autogenous cancellous bone and close the incision ( Fig. 23.2 ).

    FIGURE 23.2, Tuberculosis of calcaneus before (A) and 6 months after (B) curettage, grafting with cancellous bone chips, and primary closure of wound. The calcaneus healed without drainage, an excellent result. SEE TECHNIQUE 23.1 .

  • ▪

    In the presence of secondary infection, omit the bone grafts and close the incision loosely over drains.

Postoperative Care

A short leg cast is applied with appropriate windows cut out for dressing the wound. Immobilization is continued for 3 to 4 months, and weight bearing is permitted during the latter part of this period.

When lesions involve the subtalar or midtarsal joints, a triple arthrodesis is indicated (see Chapter 34 ). When the subtalar and the ankle joints are affected, posterior arthrodesis (see Chapter 11 ) of these joints can be done.

Excision of Bones

When the disease is extensive, especially when complicated by sinuses or secondary infection, excision of bones or amputation is indicated. Involvement of a phalanx or metatarsal often is best treated by excision. When a tarsal bone is excised, a proportionate amount of bone is taken from the opposite side of the foot so that proper alignment can be maintained.

When a metatarsal is excised, amputation of the corresponding toe permits better approximation of adjacent metatarsals and provides a foot with a better appearance and function. Excision of the first metatarsal should be avoided, if possible.

Excision of Metatarsal

Technique 23.2

  • ▪

    In the presence of secondary infection, make a longitudinal incision over the affected bone extending from the distal row of the tarsus to the middle of the proximal phalanx.

  • ▪

    Expose the bone without injuring the extensor tendons.

  • ▪

    Excise the bone with the periosteum intact and close the wound loosely over drains.

Postoperative Care

A short leg cast is applied. When the wound has healed, protective weight bearing is begun.

Usually, more than one bone is involved, so an anterior tarsectomy is required. To obtain satisfactory alignment of the foot, part of the cuboid must also be removed.

Excision of Cuneiform Bones

Technique 23.3

  • ▪

    Make a 5-cm longitudinal incision laterally and expose the joint between the cuboid and fifth metatarsal.

  • ▪

    Approach the first cuneiform and the base of the first metatarsal through a similar medial incision.

  • ▪

    Expose the second and third cuneiforms by subperiosteal dissection.

  • ▪

    Excise the anterior half of the cuboid and the three cuneiforms with an osteotome.

  • ▪

    Resect the articular cartilage from the anterior surface of the navicular and the bases of all five metatarsals.

  • ▪

    Approximate the denuded surfaces of the metatarsals to those of the navicular and cuboid.

  • ▪

    Close the incisions.

Postoperative Care

A short leg cast is applied, and protected weight bearing is begun when the wound has healed.

Excision of Navicular

Technique 23.4

  • ▪

    Expose the midtarsus through an anterolateral approach.

  • ▪

    Make an additional medial incision to expose the navicular.

  • ▪

    Excise the navicular by sharp subperiosteal dissection. Avoid injuring the dorsalis pedis artery and the branches of the deep peroneal nerve on the dorsum of the foot.

  • ▪

    Expose the calcaneocuboid joint and excise the articular cartilage and subchondral bone from the distal end of the calcaneus and the proximal one third of the cuboid.

  • ▪

    Remove the articular cartilage from the head of the talus and from the proximal surfaces of the cuneiforms.

  • ▪

    Approximate the raw surfaces of the denuded bones, obliterating the space. The position can be maintained by crossed, threaded wires.

  • ▪

    After excision of the navicular, a midtarsal arthrodesis should be performed to stabilize the foot in satisfactory alignment.

Postoperative Care

A short leg cast is applied, and protected weight bearing is begun when the wound has healed.

Excision of Cuboid

Technique 23.5

  • ▪

    Approach the cuboid through an anterolateral approach and excise it by sharp subperiosteal dissection.

  • ▪

    Resect the articular surfaces and adjacent bone from the proximal aspect of the cuneiforms and the fifth metatarsal and from the distal surface of the calcaneus.

  • ▪

    Excise the navicular and remove the articular surface and superficial bone from the head of the talus.

  • ▪

    Approximate the denuded surfaces of the bones and maintain the position by crossed, threaded wires.

Postoperative Care

Postoperative care is the same as for excision of the navicular just described.

Calcanectomy produces considerable disability, but the result may be preferable to amputation. Partial calcanectomy has long been used for the treatment of osteomyelitis of the calcaneus, with less disability and better cosmetic and functional results than total calcanectomy ( Fig. 23.3 ), although there are few reports of its use in patients with tuberculous infection.

FIGURE 23.3, Partial calcanectomy.

Excision of Calcaneus

Technique 23.6

  • ▪

    Begin a Kocher incision (see Technique 1.18) 10 cm proximal to the lateral malleolus and follow the lateral border of the Achilles tendon to the superior surface of the calcaneus; continue it inferiorly to the lateral malleolus and end it 2.5 cm distal to the calcaneocuboid joint.

  • ▪

    Divide the calcaneofibular ligament and displace the peroneal tendons superiorly and anteriorly.

  • ▪

    Incise the capsule of the calcaneocuboid joint and divide the ligamentous attachments of the calcaneus in this area.

  • ▪

    Insert a periosteal elevator or lamina spreader into the subtalar joint and divide the interosseous talocalcaneal ligaments.

  • ▪

    Dislocate the subtalar joint; use sharp subperiosteal dissection to free the soft tissues from the medial, anterior, and posterior surfaces; and divide the attachment of the Achilles tendon.

  • ▪

    Deliver the calcaneus from the wound. Avoid injuring the tibial nerve and vessels on the medial side of the bone.

  • ▪

    Suture the Achilles tendon to the inferior surface of the talus and to the short muscles of the foot.

Postoperative Care

A long leg cast is applied with the knee in 30 degrees of flexion and the ankle in moderate equinus. At 3 weeks, the cast is changed to a short leg cast, and the foot is maintained in mild equinus. Protective weight bearing is begun at 8 weeks, and cast immobilization is continued for 4 months. A shoe insert with heel elevation is required later.

Hutson et al. described excision of the talus through an anteromedial approach, followed by insertion of antibiotic beads, for the treatment of infection before tibiocalcaneal arthrodesis.

Excision of Talus

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