Addressing Advanced Active Koch’s Knee with Bone Destruction: Can Arthroplasty Be a Solution?
Tuberculous arthritis is a rare but serious condition that primarily affects large joints such as the knee, hip, and spine. Despite advances in medical science, managing advanced stages of osteoarticular tuberculosis remains a challenge. The knee, being one of the more frequently affected sites, presents complex cases that often lead to bone destruction and significant mobility impairment. One question that arises in these cases is whether arthroplasty can serve as a viable solution for patients with advanced active Koch’s knee. This blog explores that possibility based on clinical findings and recent evidence.
What Is Koch’s Knee?
Koch’s knee refers to the manifestation of tuberculous arthritis in the knee joint. While tuberculosis is generally associated with the lungs, it can affect joints and bones, leading to what is termed osteoarticular tuberculosis. Less than 3% of extra-pulmonary tuberculosis cases involve the knee, and its rarity often results in delayed diagnosis, causing the disease to progress and worsen. When advanced, it can cause severe pain, discharging sinuses, and bone destruction.
Case Study Overview
In a recent case, a 50-year-old female presented with a 3-year history of right knee pain, swelling, and immobility. Despite multiple antibiotics and cultures, no infection was initially identified. However, further investigations revealed tuberculosis of the knee, confirmed through TB CBNAAT (Cartridge-Based Nucleic Acid Amplification Test), culture sensitivity, and histopathological examination, showing granulomatous lesions with caseous necrosis.
The patient was started on antituberculosis treatment (ATT) and underwent arthroscopic debridement and wash. Following a period of bed rest and continuation of ATT, the question arose: could a total knee arthroplasty (TKA) be the next step?
Arthroplasty for Advanced Koch’s Knee
Total knee arthroplasty (TKA) is often considered for patients with advanced joint disease, including cases with severe bone destruction due to Koch’s knee. Evidence from clinical studies and case reports suggests that TKA can be effective even in the context of active tuberculosis, provided that the infection is controlled, and patients receive adequate pre-operative and post-operative care.
Benefits of TKA in Tuberculous Arthritis
- Improved Functionality: TKA significantly improves joint function and mobility. In advanced cases of tuberculous arthritis, where patients are often bedridden or unable to walk, the procedure restores joint mechanics and allows for weight-bearing activities.
- Pain Relief: Pain management is a crucial component of treating tuberculosis of the knee. TKA offers significant relief from chronic pain caused by joint destruction.
- Symptomatic Relief: Patients experience relief from symptoms such as swelling, effusion, and deformity of the knee joint.
Key Considerations for Success
- Pre-Operative Management: It is crucial to start patients on antitubercular prophylactic antibiotics at least two weeks before the surgery. This helps to control the infection and prevent recurrence.
- Wide Surgical Debridement: One of the cornerstones of success in TKA for Koch’s knee is the wide surgical debridement of all infected tissues. This reduces the risk of post-operative complications related to residual foci of infection.
- Post-Operative Chemotherapy: After surgery, continuing antitubercular chemotherapy for at least 1½ years ensures that the infection is completely eradicated, minimizing the risk of re-infection.
- Long-Term Follow-Up: Long-term follow-up is essential to monitor the progress of the patient and ensure that there is no recurrence of tuberculosis. In the case discussed, patients were followed up for a mean period of 4.4 years, demonstrating the long-term benefits of TKA in advanced cases of Koch’s knee.
Discussion of Current Evidence
A review of available literature indicates that previous tuberculosis infection of the knee does not preclude total knee arthroplasty. Studies have shown positive outcomes in patients who underwent TKA for advanced active tuberculosis of the knee. A systematic review found that among 40 studies, five were able to confirm the successful outcome of TKA in tuberculous arthritis.
A follow-up of patients between 6 and 28 months post-surgery has shown that TKA significantly improves joint function and living conditions. Moreover, studies on both staged and one-stage TKA have revealed that, on average, patients with advanced active tuberculosis of the knee can achieve functional improvement and symptomatic relief with a follow-up period extending beyond four years.
Conclusion: Is Arthroplasty a Solution?
Yes, total knee arthroplasty can be a solution for patients with advanced Koch’s knee, provided the infection is well-controlled through pre- and post-operative measures. While managing tuberculosis in the context of joint destruction is challenging, recent evidence supports TKA as a safe and effective treatment option. With the right precautions and careful follow-up, patients can regain mobility, experience pain relief, and improve their quality of life. However, it is critical that such procedures are conducted by experienced surgeons familiar with the unique complications of tuberculous arthritis.
Arthroplasty is not a last resort but a promising option for patients suffering from advanced tuberculous arthritis of the knee, paving the way for better functional outcomes and improved patient satisfaction.
