Bones of contention: Orthopedic challenges in managing osteoarticular tuberculosis for a TB-Mukt Bharat

Tuberculosis (TB), despite years of efforts toward its control and elimination through dedicated national programs, remains one of the most enigmatic public health concerns in India. Pulmonary TB remains the primary focus of this fight as it is the most prevalent and contagious form and is thought to be the only cause of the spread of the disease in society. Extrapulmonary tuberculosis (EPTB), which accounts for about 15-25% (up to 40% of the HIV positive population),¹ poses unique challenges in diagnosis and management, which are often under-recognized yet critical in India’s journey toward a TB Mukt Bharat.

Osteoarticular TB accounts for nearly 20–24% of EPTB cases.² These cases present a diagnostic dilemma for clinicians and orthopedic surgeons due to their myriad presentations. Osteoarticular TB, therefore, operates in a grey zone of uncertainty and clinical ambiguity.

Pulmonary TB, which has been at the center of our efforts to eliminate TB, is a widely researched area. It has well-defined clinical and microbiological criteria and a well-defined management algorithm. Orthopaedicians are usually the first point of contact for patients with non-specific complaints of joint or bone pain, swelling, or restricted mobility. Unlike pulmonary TB, but like the other forms of EPTB, the paucibacillary nature of osteoarticular TB makes it difficult to confirm microbiologically. Molecular diagnostics like Cartridge-Based Nucleic Acid Amplification Test (CBNAAT), which forms the backbone of TB diagnostics in the national program, are well suited for the detection of pulmonary TB; however, it has a very poor yield in osteoarticular TB. No single diagnostic test [Acid-fast bacilli smear, culture, histology/cytology, CBNAAT/ line probe assay] could ascertain the diagnosis of TB in all cases.³ The diagnosis, therefore, relies heavily on clinical suspicion, radiologic evaluation, and histopathology, making imaging tools like magnetic resonance imaging (MRI) and computed tomography indispensable. The radiological interpretations may be very useful for diagnosing advanced stages and complications of the disease, but for diagnosis in the early stage, MRI is the most important radiological tool.

This form of TB is an orthopedic masquerader mimicking a wide range of chronic musculoskeletal disorders like rheumatoid arthritis, pyogenic osteomyelitis, and bone tumors, leading to delays in diagnosis and treatment. These delays often result in irreversible joint destruction, spinal deformities, and long-term disability, particularly in young, economically productive individuals. These advanced-stage complications often require surgical intervention besides Anti-tubercular treatment (ATT) and may have poor functional outcomes.

There is also a lack of consensus on the optimal duration of ATT for various presentations of osteoarticular TB, and opinion varies between regimen-based fixed duration of treatment to prescribing ATT till healed status is demonstrated on contrast MRI/positron emission tomography. The emergence of drug resistance has added to the complexity of the diagnosis and treatment of osteoarticular TB. Some data have started emerging on presumptive (suspected) drug-resistant cases, their laboratory investigations, and treatment. Recently, Jain et al. (2024) presented an algorithm for these cases.⁴ However, this needs to be validated through much larger multicentric studies.

Surgical intervention in osteoarticular TB is usually reserved for refractory cases, spinal instability/neural deficit, or complications such as abscesses. The decision to operate demands orthopedic expertise and time-sensitive judgment. The cases of osteoarticular and spinal TB presenting at advanced stages of the disease usually need complex surgical interventions. The variability of surgical infrastructure, expertise, and complexity of cases leads to variability in outcomes. In these patients, post-operative care, deformity correction, and long-term rehabilitation are crucial outcomes that define patient quality of life, something far beyond microbiological cure.

India’s National TB Elimination Program (NTEP) has made significant progress in access to free diagnostics, treatment, and drug resistance monitoring, but they are largely focused on pulmonary TB. When it comes to extrapulmonary TB, like osteoarticular TB, the program still faces big gaps primarily because of the lack of a well-defined algorithm for early detection (CBNAAT and other microbiological tests, including culture, have poor yield) as well as issues related to tissue yield and management, unlike pulmonary TB. Management of osteoarticular TB requires multidisciplinary integration and the spread of awareness among peripheral healthcare providers.

To achieve the vision of a ‘TB Mukt Bharat’, we must adopt a more holistic and inclusive approach to TB management, where there is no ‘Chest versus the Rest of the TB divide’! A national program designed to eliminate TB cannot afford to overlook a quarter of its burden. The vital role orthopaedicians play in the detection, treatment, and rehabilitation of osteoarticular TB must be recognized. They must be actively integrated into the national TB Elimination strategy, not merely as caregivers, but as programmatic partners, researchers, and educators. Resident training programs must include structured modules on osteoarticular TB. There is also a need for clear referral pathways to enable timely specialist intervention, especially in peripheral and underserved areas. The time has come when we must also question the appropriateness of extrapolating pulmonary TB diagnostic and treatment protocols to manage complex forms such as spinal TB and other cases of deep-seated bones and joint lesions or indolent cases like tubercular dactylitis. Each osteoarticular form of TB requires tailored approaches, and such nuances need to be integrated within NTEP’s framework at the earliest.

In a country that has the highest global TB burden, every delayed or missed diagnosis of osteoarticular TB represents a missed opportunity to end this disease. As India strives to achieve its ambitious goal of TB elimination five years earlier than the United Nations Sustainable Development Goals of 2030, orthopedicians must contribute not only through diagnostic and surgical tools but also with a systemic voice in the national TB elimination strategy.

In the country’s defining fight against TB, bones also have a story and orthopedicians hold a role and responsibility that the program must realize!