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Background questions

What are the risk factors for osteoarticular TB?


What is the best investigation to confirm the diagnosis of osteoarticular TB?
What is the best end point of OA TB clinical/laboratory/imaging?
What how do you measure response to treatment in OA TB?
Foreground questions
What is the safe duration of chemotherapy in osteoarticular TB?
Are relapse rates higher in short course chemotherapy?
What regime is best for OA TB?
Is intermittent therapy as effective in OA TB?

Formulation of Questions
Population
1. What is the population at risk for osteoarticular TB\? Men, women or
children?
2. Is any prophyllaxis possible for those at risk?
3. If yes, who definitely needs prophyllaxis?
4. Is there any specific vulnerability factor for different parts of the skeletal
system for involvement?
5. Is there any way of predicting the area of involvement in a given
population?
Interventions
Diagnostics
Clinical
1. What are the clinical features suggestive of osteoarticular TB?

2. What are the minimum clinical criteria for clinical diagnosis of


osteoarticularTB?
3. What are the clinical features for follow up?
4. What should be the frequency/ periodicity of clinical follow up?
5. What are the clinical indicators for surgical intervention?
6. What are the minimum clinical criteria of slow responders?
7. What are the criteria for failure of treatment?
8. What are the clinical features of relapse?
9. What are the clinical features of MDR/XDR TB?
10.What are the clinical features for referring a case to a tertiary level
centre?
Laboratory
1. What are laboratory tests for confirming diagnosis of OA TB?
2. What are the laboratory tests for follow up of patients?
3. What is the frequency and periodicity of these tests?
4. What are the tests for failure of treatment/ Resistance?
5. What are the indications for these?
6. What are the minimum tests to be done in every case for diagnosis?
7. What are the minimum tests for follow up?
8. What are the tests for referral of a given case?
9. What are tests required at different levels; Primary/Secondary/Tertiary?
10.What are the criteria to eliminate or include a new investigation in
management of a case?
Imaging
Radiography
1. What minimum views are required for diagnosis?
2. What are the specific diagnostic features to label a case a case of OA TB?
3. What should be the periodicity for getting these images done?
4. Should pulmonary screening be mandatory in all cases?
5. If no, what are the indications for pulmonary screening?
6. What are the indications for screening of contacts in a case of OA TB?
7. What are radiological features of response to treatment?
8. What are the radiological features of healing?
9. What are the indications for ordering alternative imaging modalities?
10.What are the indications, if any, for follow up radiography after completion
of treatment?
11.What are the radiological features of recurrence?
12.What criteria must be used for follow up of these cases?
Ultra sonography
1. What are the indications for USG in a given case of OA TB?
2. What minimum equipment/ probe should be available for OA TB
evaluation?

3. What are the diagnostic criteria in a given case?


4. What should be periodicity of USG for follow up of cases?
5. When should USG guided biopsy or aspiration be done in a case of OA TB?
MRI
1. What are the indications for MRI in a case of OA TB.
2. What are the minimum diagnostic criteria for diagnosing active TB in OA
TB?
3. What are the indications for contrast enhanced MRI in a case?
4. Are there any indications for higher Tesla imaging with MRI?
5. Should the whole skeletal system be screened in every case or only
localised MRI suffice?
6. What are the indications for repeat MRI in a given case?
7. What are the MRI criteria for response to treatment?
8. What are the MRI criteria for failure of treatment?
9. What should be imaging modality in a case where MRI is contraindicated?
10.What are MRI features suggestive of complete healing in OA TB?
11.What are MRI features of relapse of TB in a case of OA TB?
CT Scan
1.
2.
3.
4.
5.

What are the indications for CT scan in OA TB?


What are the features diagnostic/ suggestive of OA TB in CT Scan
What are the features of activity or healing in CT imaging?
Is there any role for contrast enhanced CT in a case of OA TB?
What are the indications for CT guided biopsy?

PET Scan
1.
2.
3.
4.

What are
What are
What are
What are
done?

the
the
the
the

indications for a PET scan in OA TB?


PET scan characteristics of active TB in OA TB?
PET scan characteristics of healing in OA TB?
alternative investigations for those in whom PET cannot be

indications for nuclear imaging in a case of OA TB?


features suggestive of TB in nuclear imaging?
features of activity in OA TB?
features of healing in a case of OA TB?
features of relapse on nuclear imaging in a case of OA TB?

Nuclear Imaging
1.
2.
3.
4.
5.

What
What
What
What
What

are
are
are
are
are

the
the
the
the
the

What
What
What
What

are
are
are
are

the indications for biopsy?


indications for needle biopsy?
the indications for open biopsy?
histological features of active TB on biopsy?

Biopsy
1.
2.
3.
4.

5. What are the features of relapse in OA TB?


6. What should be the approach for deep inaccessible areas?
7. What should be the approach if biopsy is negative for tissue but clinically
looks like TB
Culture and AFB
1.
2.
3.
4.
5.
6.
7.

What staining is sufficient for AFB ZN on Fluoro Staining?


What should be protocol for AFB negative but Biopsy shows Granuloma?
What are confirmatory requirements in a specimen of tissue/ Pus?
What additional test should be done in a case which is culture negative?
Is culture mandatory in all cases?
At what stage should repeat culture be done?
What should be done if repeated cultures are negative and disease looks
active clinically?
8. What are the indications for drug sensitivity in a given case?
9. What should be the minimum drugs against which sensitivity must be
done in a case of OA TB?
10.Is extended sensitivity required in any case at the beginning?
11.If yes what are those cases? HIV/ Health care worker/ family member with
MDR or XDR TB/ DM/ others.
12.What are the indications for sending a specimen to a referral laboratory?
13.Is transport medium required for transporting specimens in remote areas?
If yes what is/are the transport medium(s) preferred?
14.What should be done if no transport medium is available?
Treatment
1. What regime is ideal for OA TB?
2. What is the dosage for each of these?
3. What should be the duration of treatment?
4. Is short course chemotherapy possible in OA TB?
5. If yes, what is the appropriate duration?
6. Is it advisable to start ATT without tissue diagnosis?
7. Is empirical ATT advisable on clinical grounds?
8. What are the indications, if any, for trial of ATT?
9. Is short course chemotherapy effective in OA TB?
10.Is intermittent therapy advisable in OA TB?
11.What are the end points of treatment? Clinical/ laboratory/
imaging/others?
12.What are the criteria for declaring a patient as a slow responder?
13.What are criteria for failure of treatment OA TB?
14.When and what drugs would you start in a case of failure of response to
treatment? When culture sensitivity is available/ when it is not available?
15.How long do you continue drugs in slow responders?
16.What is the duration of therapy in resistant cases of OA TB?
17.How do you decide the end point in resistant cases?

18. When do you decide a patient needs surgery in addition to


chemotherapy?
19.What are the indications for stopping treatment because of side effects?
20.How do you decide to restart after stoppage?
21.How long can default in therapy be tolerated safely without change in
regime? What are the criteria for decision making in such a case?
22.When should regime change be considered for default in treatment? What
should be the change?
Surgery
1.
2.
3.
4.
5.
6.

What are indications for surgery when a patient is on chemotherapy?


How long do you continue therapy after surgery?
What are the criteria for fusion of joints in surgery?
What are the criteria for stabilization of joints and bone using implants?
Do you have to use Titanium implants or are stainless steel implants safe?
When can joint replacements be done safely in a case of joint
involvement?
7. What are the indications for cage and bone grafting in a case of OA TB?
8. What are the indications for drainage of abscess in OA TB?
9. What are the indications for surgery for discharging sinuses?
10.What are the indications for reoperation in cases of OA TB?
11.What should be duration of follow up? Essential? Desirable?
Bracing
1. What are the indications for bracing in a case of OA TB?
2. How long braces should be continued?
Physiotherapy
1.
2.
3.
4.

When
When
When
When

do you start physiotherapy in a case of joint involvement in OA TB?


do you start Joint mobilization in a case of OA TB?
do you start weight bearing in case of lower limb OA TB?
can athletic activities be permitted after therapy for OA TB?

Specific Situations
Spine
1. Any difference in Drug regime when there is paralysis and when there is
no paralysis?

2. Any difference in duration of regime when there is paralysis and when


there is no paralysis?
3. What are the indications for surgery?
4. How do you decide on the type of surgery?
5. What are the indications for drainage of psoas/ prevertebral abscess?
6. What are the indications for stabilization of spine?
7. What is the best implant for surgery?
8. What are the indications for bone grafting?
9. Should chemotherapy be continued until recovery of paralysis?
10.How long chemotherapy should be continued after recovery of paralysis?
11.Is there a difference in surgery in different age groups?
12.Do children need special investigation/surgery/regime for spine?
Weight bearing lower limb bone and joints
1. What are indications to keep the patient non weight bearing/partial weight
bearing?
2. What are the indications of bracing? What is the best brace?
3. When should major joints of Hip/Knee and Ankle be mobilized?
4. In synovitis cases how do you decide end of treatment?
5. What are the indications for arthrodesis?
6. What are the indications for joint replacement?
7. What is the safe period for these surgeries? Can they be done in active
TB?
8. In healed cases when should prophylactic therapy be started and how
long should it be continued?
9. Are there any implant specifications in active TB/ healed TB?
In Upper limb cases
1.
2.
3.
4.

What
What
What
What

is the safe period for rest and mobilization?


are the indications for arthrodesis?
are the indications for arthroplasty?
should be the duration of bracing?