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Tubercular Osteomylitis After Fracture Fixation – A Case Report

 Manoj Kumar Goyal*,Anil Arora**

* Senior Resident
UCMS & GTB Hospital,University of Delhi,New Delhi ,India

Address for Correspondence:  

Dr. Manoj kumar goyal
175, first floor, state bank nagar,
Paschim Vihar,
New Delhi [India]
+91 9312813298, +91 11 25266298
fax +91 11 25893390


J.Orthopaedics 2008;5(2)e17


Tubercular arthritis has been reported following prosthetic joint in the literature1-5 but tubercular osteomylitis around fracture fixation implants is extremely rare. We are reporting a case of tubercular osteomylitis of femur after subtrochentric fracture fixation

Case Report :

A 38yrs male reported to us with discharging wound over an exposed plate on lateral aspect of proximal thigh [figure-1]. He had subtrochentric fracture of femur, which was fixed 2 months back. The postoperative period was uneventful up to one month, after which patient developed pain and sinus at operative site. The size of sinus increased despite multiple antibiotics.

All routine blood investigations including erythrocyte sedimentation rate was normal. Gram’ staining and acid fast bacilli staining were negative. Chest x-ray was normal. The x-ray of femur with hip joint showed subtrochentric fracture with dynamic hip screw plate fixation with no sign of union and normal bony architecture [figure-2]. The polymerase chain reaction [PCR] test for mycobecterial tuberculosis was positive.

After considering endemicity of tuberculosis along with clinical evidences and positive PCR for mycobecterial tuberculosis, the diagnosis of tuberculosis was made. Standard multidrug antitubercular therapy was given. After 6 weeks, size of wound decreased with no discharge [figure-3]. After 12 weeks, the wound was completely healed [figure-4]. At this stage signs of union were present in x-ray. After 18 weeks, the fracture line was invisible. Antitubercular therapy was continued for one year. Recent follow up at 3 years revealed no recurrence of the infection.   

Fig 1: Clinical photograph at the time of presentation.

Fig 2: X-rays, at the time of presentation.

Fig 3: After 6 weeks of starting of antitubercular therapy


Fig 4: After 12 weeks of starting of antitubercular therapy.


It is extremely rare to find tuberculosis causing deep infection around implants following open reduction and internal fixation of closed fractures. Very few reports have been published in the literature6.

Tubercular bacteria can involve an implant site by hematogenous spread from activation of a latent distant focus or local reactivation of dormant bacteria in a previously exposed individual. Major trauma can cause lowering of both humeral and cellular immunity in its initial stages7-9. Under such circumstances, reactivation of a mycobacterium can occur at a latent site, such as lung, kidney, or mesenteric lymph nodes, resulting in subsequent seeding at the implant site.1 Local reactivation can be precipitated by trauma or surgery and has been described as occurring as long as forty-two years after the initial surgery10. It seems that any factor that alters the local tissue response can potentially precipitate this phenomenon. We speculate that decreased immunity in response to trauma allowed reactivation of latent bacteria at a distant focus, with subsequent seeding at the implant site in these patients.

The modern antitubercular drugs isoniazid, rifampicin, pyrazinamide, and ethambutol are very effective and safe. There is no osseous barrier in osteoarticular tuberculosis to penetration of antitubercular drugs11.

While osseous tuberculosis as a late complication of the surgical treatment of closed fracture is atypical and rare, we believe that tuberculosis should be kept in mind as a possible cause of deep infection, especially in zones endemic for tuberculosis. In zones in which tuberculosis is not endemic, patients with persistent, recalcitrant or atypical infection should undergo laboratory investigations for mycobacterial infection.   

Reference :


  1. McCullough CJ. Tuberculosis as a late complication of total hip replacement. Acta Orthop Scand. 1977;48:508-10.

  2. Spinner RJ, Sexton DJ, Goldner RD, Levin LS. Periprosthetic infections due                                                              to mycobacterium tuberculosis in patients with  no prior history of tuberculosis. J Arthroplasty. 1996;11:217-22.

  3. Lusk RH, Wienke EC, Milligan TW, Albus TE. Tuberculosis and foreign body granulomatous reaction involving total knee prosthesis. Arthritis Rheum. 1995;38:1325-7

  4. Wolfgang GL. Tuberculosis joint infection following total knee arthroplasty. Clin Orthop Relat Res. 1985;201:162-6.

  5. Berbari EF, Hanssen AD, Duffy MC, Stecklberg JM, Osmon DR. Prosthetic joint infection due to Mycobacterium Tuberculosis: a case series and review of the literature. Am J Orthop. 1998;27:219-27.

  6. Kumar S, Aggarwal A, Arora A. Skeletal tuberculosis following fracture fixation. A report of five cases. J Bone Joint Surg Am. 2006;88:1101-6.

  7. Rodrick ML, Wood JJ, O’Manony JB, Devis CF, Grbic JT, Dermling RH, Moss NM, Saporoschetz I, Jordon A, D’eon P, Mannick JA. Mechanisms of immunosuppression associated with severe nonthermal traumatic injuries in man: production of interleukin 1 and 2. J Clin Imunol 1986;6:310-8.

  8. Lyons A, Kelly JL, Rodrick ML, Mannick JA, Lederer JA. Major injury induces increased production of interleukin-10 by cells of the immune system with a negative impact on resistance to infection. Ann Surg. 1997;226:450-60.

  9. Browder W, Williams D, Pretus H, Olivero G, Enrichens F, Vao P, Franchello A. Beneficial effect of enhanced macrophage function in the trauma patient.       Ann Surg 1990;211:605-13.

  10. Johnson R, Barness KL, Owen R. Reactivation of tuberculosis after total hip replacement. J Bone Joint Surg Br. 1979;61:148-50.

  11. Barclay WR, Ebert RH, Le Roy GV, Manthei RW, Roth LJ. Distribution and excretion of radioactive isoniazid in tuberculosis patient. J Am Med Assoc.1953;151:1384-8.



This is a peer reviewed paper 

Please cite as : Manoj Kumar Goyal : Tubercular Osteomylitis After Fracture Fixation – A Case Report

J.Orthopaedics 2008;5(2)e17





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