The Knee Vol. 2. No. 1, pp.

Z-56, 1995
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Case report
Tuberculosis of the patella: report of a
case and review of the literature

Mandeep S Dhillon, C Rajasekhar, 0 N Nagi

Department of Orthopaedics, Postgraduate Institute of Medical Education and Research,
Chandigarh, India

Summary

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.

Key words: Osteolytic lesions, tuberculosis, patella

The Knee Vol. 2, No. 1, 53-56, 1995

Introduction sedimentation rate of 20 mm h-l (Westergren). The

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, and only eight such caseshave
previously been reported in the literatureld. 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 2%year-old man, hotel attendant by occupation,
presented to us in September 1993 with the complaints
of pain and swelling in the left knee joint of 2 months
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 mmm3with mild lymphocytosis and an erythrocyte
Accepted: January 1995
Correspondence and reprint requests to: MS Dhillon
1241 Officer’s Apartments, Sector 24-B, Chandigarh
Mantoux test for tuberculous infection sensitivity gave
an induration of 22 mm at 48 h. A radiograph of his
chest was normal. Lateral and skyline views of the knee
joint showed an osteolytic lesion in the inferior pole of
the patella with no involvement of the articular surface
and no surrounding sclerosis (Figure 1). Computed
tomographic scan of the knee joint showed an osteo-
lytic lesion in the centre of the patella, with a hazy zone
in the centre (presumably a sequestrum) (Figure 2).
Clinically and radiographically a presumptive diagnosis
of benign bone tumour was made and the possibility of
tuberculosis was considered. Fine needle aspiration
cytology was attempted but failed to penetrate the
bone. Patellectomy was performed and the lesion was
subjected to histopathological examination. The patho-
logist reported it to be a degenerative lesion with no
features suggestive of neoplastic or infectious origin.
The pain and effusion decreased and the patient was
relatively symptom free for a period of 3 months. The
patient then presented with diffuse swelling, pain and
complete restriction of movement. Clinical evaluation
showed diffuse tenderness, fluctuation and loss of
movements. Radiography of the knee joint revealed
nothing but diffuse osteaporosis. The patient was
subjected to an arthrotomy of the involved joint. On
synovial fluid analysis, 3-9 acid fast bacilli in concentra-
tion smears, a sterile culture and non-specific synovitis
on histopathological examination was observed. A
repeat arthorotomy was done with the aim of syno-
MS, MNAMS, vectomy and joint debridement which yielded positive
160023, India cultures for Mycobacterium tuberculosis when grown in
54 The Knee Vol 2 No 1 1995

Table 1. Review of the literature

Radio-
No. of Sex Age Site in Clinical graphical
Author Year Reference cases (M/F) (years) pa tella features features Treatment

Harto- 1969 2 3 2MllF 7-57 2 proximal Pain, Osteolytic All three

filakidis- (mean 32) pole effusion lesion, no patellectomy,
Garofalidis 1 destroyed swelling mention of one ultimately
patella sclerosis or involved joint
sequestrum
Hernandez- 1987 3 1 M 8 Middle Effusion, Lytic lesion Sequest-
Gimenez synovial sclerosis rectomy,
et af. thickening Al-l-.
Martini and 1988 4 1 - - Middle Osteolytic Refused treat-
Boudjema lesion ment: 6
months later
- debride-
ment,
arthrodesis
and Al-f.
Shah and 1990 5 M 25 Centro- Effusion, Osteolytic Patellectomy
Ramakantan medial restricted lesion, no and AIT
flexion sclerosis or
sequestrum
Tuli 1991 6 1 - - Proximal - Osteolytic ATT and
pole lesion, functional
some treatment
sclerosis
Bonnet 1992 1 1 M 48 Middle No effusion Osteolytic Partial
et a/. or synovial lesion with excision and
thickening sequestrum ATT

ATT = antituberculous therapy

Lowenstein-Jenson’s medium. The patient was then
started on antituberculous drugs (rifampicin 600 mg,
ethambutol 1 g, isoniazid 300 mg and pyridoxine
10 mg, all in a single dose schedule) which yielded a
definite symptomatic improvement within six weeks.
At the time of writing (September 1994), the patient
had minimal pain, was walking with full weight bearing
but had restriction of knee flexion to 60”.
Discussion
Isolated tuberculous involvement of the patella is
extremely uncommon and to the best of our knowledge
only eight such caseshave been reported in the English
literaturer.“. 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 underdeveloped countries where
this diseaseis still prevalent, and in developed countries
where a resurgence of tuberculosis has recently been
noticed in immunocompromised patients. It is import-
ant that tuberculosis be included in the differential
diagnosis of all osteolytic lesions of the patella.
From an epidemiological point of view, the knee
joint is the third most common joint involved in
tuberculosis in the body4,6. The patella however, as a
primary site, is most uncommonly involved. In a review
of 1074 osteoarticular tuberculous lesions Tuli reported
an incidence of 90 cases (8.3%) involving the knee,
only one (0.09%) of which was localized in the patella.
Martini and Boudjema4 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 tuber-
culosis patients seen over a 46 year period in a hospital
mainly for skeletal tuberculosis, only two cases had
cystic tuberculosis of the patella2. 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.
Although cystic lesions of the patella are rare, an
increasing number of cases are being reported in the
orthopaedic literature 7,8. The differential diagnosis of
such lesions includes tumours like chondroblastoma,
osteoid osteoma, aneurysmal bone cyst, metastases or
brown tumour and even gout and infectious pathology.
Previous authors have suggested that the absence of
sclerosis and location in a para-articular region should
suggest tuberculosis5. However, a review of the liter-
ature has revealed only one common denominator in
 Dhillon et al.: Tuberculosis of the patella 55

Figure 2. Computed tomographic image showing

osteoiytic lesion with marginal sclerosis. Note the flaky
sequestrum.

Figure 1. Radiographs showing: ia) lateral view of an

osteolytic lesion at the inferior pole of the patella, and
(b) skyline view of a central osteolytic lesion in the Figure 3. Anterior (a) and posterior (b) aspects of the
patella with marginal sclerosis. excised patella. There is no evidence of cortical break.

radiographical findings; an osteolytic lesion in the
patella. Some authors have reported sclerosis around
this while others have found none. Nevertheless, a
sequestrum has been reported in more than half of
these cases, and we believe that this flaky sequestrum
may perhaps 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 dia-
gnosis is essential, and some form of biopsy either
excisional or incisional is required. We did a patel-
lectomy in our case and found that the bone had not
been penetrated by the diseasein any direction (Figure
3). Inadvertant periosteal stripping of the extensor
expansion, however may have led to seeding of the
56 The Knee Vol 2 No 1 1995
synovium which resulted in widespread synovial disease
and a poorer end result. We now advocate anterior
incision in the patella, adequate curettage and biopsy,
followed by the early institution of chemotherapy. If
patellectomy is to be done, then special care should be
taken to prevent synovial involvement which will lead
to a poorer end result as has also been noted
previously”. However, some cases may show general-
ized involvement at initial presentation, which makes
the diagnosis easier, but the prognosis worse.
References
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3 Hernandez Gimenez M, Beltran JVT, Sequi MIF,
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1987;17: 328-9
4 Martini M, Boudjema A. Tuberculous osteomyelitis. In
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5 ShahP, RamakantanR. Tuberculosisof tbe patella. BP.J
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