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Tuberculosis Of The Patella In Children-Case Report

Demni  K*, Afifi  A*,Atarraf K*, hater L*, Arroud M*, Rami  M*, Bouabdallah Y*

* Department of Pediatric Surgery, University Hospital FES, Morocco

Address for Correspondence:

Karim Demni
Appt 23, Imm. H, Résidence AL BAIDA
Tel: (OO212) 62 01 42  75



A case of tuberculosis of the patella presenting as an osteolytic lesion without synovial involvement is described. Delay in diagnosis resulted in progression to generalized tuberculous synovitis. Clinicians should consider the possibility of a diagnosis of tuberculous osteomyelitis of the patella in patients presenting with an osteolytic patellar lesion in areas where tuberculosis is pandemic or in immunocompromised patients

J.Orthopaedics 2007;4(3)e23

Osteolytic lesions, tuberculosis, patella, children

Introduction :

Osteoarticular tuberculosis is still prevalent in under-developed countries and bizarre presentations may be encountered. In Western countries migrant populations and immunocompromized patients have recently lead to some resurgence of the disease, making tuberculosis, in all it’s forms, an important part of the differential diagnosis of cystic bone lesions.

Tuberculosis causing an osteolytic lesion in the patella is extremely rare. We describe such a case and discuss the various features, both clinical and radiological, which may help in the diagnosis. A review of the literature is presented along with a discussion of the treatment.

Case Report:

A 14 years old boy, presented to us with the complaints of pain and swelling in the left knee joint of 2 monthes duration. There was no history of trauma to the knee, fever or any chest symptoms. Clinical examination revealed no increase in local temperature over the joint, effusion or synovial thickening. Laboratory investigations showed a total leucocyte count of 7000/mm3 with mild lymphocytosis and an erythrocyte sedimentation rate of 20 mm at the first hour. The Mantoux test for tuberculous infection sensitivity gave an induration of 26 mm at 48 h. A radiograph of the chest was normal. Lateral and face views of the knee joint showed an osteolytic lesion of the patella with no involvement of the articular surface and no image of sclerosis (Figure 1-2). Clinically and radiographically a presumptive diagnosis of tuberculosis was made and the possibility of benign bone tumour was considered. Excision of the sequestrum was performed and the lesion was subjected to histopathological examination. The pathologist reported it to be a degenerative lesion with no features suggestive of neoplastic origin.

An arthorotomy was done with the aim of synovectomy and joint debridement which yielded positive cultures for Mycobacterium tuberculosis when grown in

Lowenstein-Jenson’s medium. The patient was then started on antituberculous drugs which yielded a definite symptomatic improvement.

Actually, the patient has minimal pain, walking with full weight bearing but has restriction of knee flexion to 60°.


Fig 1:  Ostéolysis lesion of the patella

 Fig 2: centrosomatic ostéolysis

Discussion :

Isolated tuberculous involvement of the patella is extremely rare (1,6). The importance of early and accurate diagnosis and the imposition of appropriate therapy is underlined by the present case; early institution of antituberculous drugs may have minimized the spread of the disease inside the joint and may have perhaps decreased the patient’s morbidity and given him a better knee function. The recognition of this pathology is important, both in our underdeveloped countries where this disease is still prevalent, and in developed countries where a resurgence of tuberculosis has recently been noticed in immunocompromised patients. It is important that tuberculosis be included in the differential diagnosis of all osteolytic lesions of the patella, especially in developed countries.

From an epidemiological point of view, the knee joint is the third most common joint involved in tuberculosis in the body (4,6). The patella however, as a

primary site, is most uncommonly involved. In a review of 1074 osteoarticular tuberculous lesions Tuli(6), reported an incidence of 90 cases (8.3%) involving the knee, only one (0.09%) of which was localized in the patella. Martini and Boudjema(4),have mentioned one case of tuberculous osteomyelitis of the patella in 652 cases (0.15%). One case of the above two did not involve the joint, while the other ultimately lead to complete joint destruction due to treatment delay. Of 10 603 tuberculosis patients seen over a 46 year period in a hospital mainly for skeletal tuberculosis, only two cases had cystic tuberculosis of the patella (2)

In spite of the rarity of this type of tuberculosis, a high index of suspicion has to be maintained to achieve a good end result especially in our countries.

Although cystic lesions of the patella are rare, an increasing number of cases are being reported in the orthopaedic literature (7,8).

Previous authors have suggested that the absence of sclerosis and location in a para-articular region should suggest tuberculosis (5). However, a review of the literature has revealed only one common denominator in radiographical findings; an osteolytic lesion in the patella. Nevertheless, a sequestrum has been reported in more than half of these cases, and this sequestrum may be a diagnostic clue.

From a treatment point of view, the basic treatment in the form of early institution of adequate anti-tuberculous therapy and guarded function can not be over emphasized. However, a tissue or bacterial diagnosis is essential, and some form of biopsy either excisional or incisional is required.

We advocate that incision in the patella, adequate curettage and biopsy, followed by the early institution of chemotherapy. Some cases may show generalized involvement at initial presentation, which makes the diagnosis easier, but with worse prognosis.

Reference :

  1. Bonnet C, DeBandt M, Palazzo E, Malaizier, D.    Tuberculosis involving the patella. Am J Roentgen01  1992; 159: 677

  2. Hartofilakidis-Garofalidis G. Cystic tuberculosis of the   patella. J Bone Joint Surg [Am] 1969; 51A: 582-5

  3. Hernandez Gimenez M, Beltran JVT, Sequi MIF,   Gomez EP. Tuberculosis of the patella. Pediatr Radio1   1987;17: 328-9

  4. Martini M, Boudjema A. Tuberculous osteomyelitis. In  Martini M, ed. Tuberculosis of the Bones and Joints.   Berlin: Springer Verlag, 1988, pp. 78-9

  5. Shah P, Ramakantan R. Tuberculosis of tbe patella. BP.    J. Radiol. 1990; 63: 3634

  6. Tub SM. Tuberculosis of the Skeletal System. New Delhi ,  India: Jay Pee Brothers Medical Publishers, 1991, pp. 3,78-9

  7. Ehara S, Khurana JS, Kattapuram SV, Rosenberg AE,    El Khoury GY, Rosenthal DI. Osteolytic lesions of the patella.   Am J Roentgen01,1989; 153: 103-106

  8. Sur RK, Singh DP, Dhillon MS, Gupta BD, Murali B,  Sidhu R. Patellar metastatis: a rare presentation. Br J      Radio1 1992; 65: 7224

This is a peer reviewed paper 

Please cite as : Demni  K : Tuberculosis Of The Patella In Children-Case Report  

J.Orthopaedics 2007;4(3)e23





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