Ali Asghar Shah  ( Orthopaedic Ward, DHQ Teaching Hospital, Abbottabad. )
Sajjad Ahmed  ( Orthopaedic Ward, DHQ Teaching Hospital, Abbottabad. )
Humayun Shah  ( Orthopaedic Ward, DHQ Teaching Hospital, Abbottabad. )
Fazle Raziq  ( Departments of Pathology, Ayub Medical College, Abbottabad. )

Eighty patients of bone and joint tuberculosis were diagnosed and treated at DHQ leaching Hospital, Abbottabad from August, 1987 to December, 1990. Majority of them were children and young adults. There were more females (57.5%) than males (42.5%). A major fraction of the cases were Afghan refugees. Most of the patients were malnourished and belonged to low socioeconomic class (JPMA 42: 180, 1992).

Tuberculosis in Pakistan occurs early in life and figures as high as 71% and 68% in 15-19 year age group have been reported with the overall infected population being 60% and 54% respectively¹. The problem has been further aggravated after the influx of Afghan refugees since 1980.

Eighty patients presenting with bones and joints infections were admitted and investigated at District Headquarter Teaching Hospital, Abbottabad from August, 1987 to December, 1990.. Relevant history included age, sex, occupation, immunisation status, history of contact, residential address with special consideration to the home district. Afghan refugees were listed separately. Patients were examined clinically and radiologically which included x-ray of the involved part and x-ray of the chest. IVU and tomography were also done when indicated. Laboratory investigations in­cluded complete blood picture with ESR, tuberculin skin test, urine examination for tubercle bacilli, aspiration of the lesion for isolation and culture of APB and sputum examination for AEB and culture. Most of the cases were confirmed on histological examination of the biopsy. Treatment consisted of standard three drugs regimen with rifampicin, INH and pyrazinamide com­bined in appropriate cases with surgical debridement or excision. There were 46 females (57.5%) and 34 males (42.5%)with an equal number of cases in age groups 0-20 years and 2 1-40 years (Table I).

The spine was involved inmost cases (21.25%) with the knee joint (15%), hip joint (11.25%) and elbow joint (10%) following (Table II).

Almost half (8 cases) of the patients with spinal tuberculosis presented with paraplegia, all of whom except one improved with surgical intervention. In 29 (36.25%) patients there was accompanying pulmonary or renal tuberculosis. One young girl of 18 years had multifocal lesions involving the ankle and spine. The distribution according to the various districts is shown in Table III.

The maximum number of patients were Afghan refugees.

The aim of treatment in joint diseases is to eradicate the pathology and preserve functions. With regard to joints this would mean a reasonable range of painless motion and good stability². In this study chemotherapy cured 65% of patients while 35% failed to respond adequately. Progressive bone destruction occurred and relapse followed after stopping the drugs. The lesion in some of these patients were a vascular and contained much caseous material or sequestra. In 9 cases the organism were resistant to the drugs used. Hence 32 patients needed surgery in addition to chemotherapy. Wilkinson has shown the value of combining surgery with chemotherapy in selected patients³.

1. Kaleta. 3. and Chaudhry, NA. Epidemiological aituation of tuberculoaia in Pakiatan. Resulta of the National Tubercuioaia Prevalence Survey 1974-78. Documents on tuberculosis in Pakiatan, documenta presented at the XIV National Tuberculosis Conference, Lahore, April, 1982, pp. 1.8.
2. Medical Research Council Working Party on Tuberculosis of the Spine. A controlled trial of ambulant out-patient treatment and patient in bed in the management of tuberculosis of the apine in young Korean patients on atandard chemotherapy. J. Bone Joint Surg., 1973; 55B:678-97.
3. Wilkinson, M.C. Tuberculosis of the hip and knee treated by chemotherapy, aynovec­ tomyanddebridement. J. Bone Joint Surg., 1969;51A:1343-59.