Two-stage TKA for tuberculosis septic arthritis of the knee masquerading as pigmented villonodular synovitis: A case report

  • Richard Samade
    Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
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  • Ryan T. Voskuil
    Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
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  • Thomas J. Scharschmidt
    Corresponding author at: Department of Orthopaedics, Orthopaedic Surgery Residency Program, The Ohio State University Wexner Medical Center, The Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, 241 11th Avenue, Suite #6055, Columbus, OH 43210, United States.
    Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
    Search for articles by this author


      A 25-year-old female presented with left knee pain following arthroscopic synovectomy for presumed pigmented villonodular synovitis (PVNS). Radiographs and magnetic resonance imaging demonstrated tricompartmental arthritic changes. She underwent a two-stage procedure first involving antibiotic spacer implantation, followed 1 week later by spacer removal and definitive total knee arthroplasty (TKA) once initial intraoperative culture results were negative. Subsequent cultures confirmed tuberculosis septic arthritis. Repeat evaluation 1 year postoperatively showed no complications and patient satisfaction with left knee function. This is a unique case report in the United States describing 1-year outcomes following staged TKA for tuberculosis septic arthritis masquerading as PVNS.


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        • Al-Shaikh R.
        • Goodman S.
        Delayed-onset Mycobacterium tuberculosis infection with staphylococcal superinfection after total knee replacement.
        Am J Orthop (Belle Mead NJ). 2003; 32: 302-305
        • Anderson D.
        • Anderson L.
        • Haller J.
        • Feyissa A.
        The SIGN nail for knee fusion: technique and clinical results.
        SICOT J. 2016; 2: 6
        • Barry M.
        • Akkielah L.
        • Askar M.A.
        • Bin Nasser A.S.
        Miliary tuberculosis with delayed-onset total knee arthroplasty Mycobacteria tuberculosis infection successfully treated with medical therapy alone: A case report and literature review.
        Knee. 2019; 26: 1152-1158
        • Boeckstyns M.
        • Backer M.
        Reliability and validity of the evaluation of pain in patients with total knee replacement.
        Pain. 1989; 38: 29-33
        • Comstock G.
        • Livesay V.
        • Woolpert S.
        The prognosis of a positive tuberculin reaction in childhood and adolescence.
        Am J Epidemiol. 1974; 99: 131-138
        • Eskola A.
        • Santavirta S.
        • Konttinen Y.T.
        • Tallroth K.
        • Lindholm S.T.
        Arthroplasty for old tuberculosis of the knee.
        J Bone Joint Surg Br. 1988; 70-B: 767-769
        • Gale D.W.
        • Harding M.L.
        Total knee arthroplasty in the presence of active tuberculosis.
        J Bone Joint Surg Br. 1991; 73-B: 1006-1007
        • Campion E.W.
        • Getahun H.
        • Matteelli A.
        • Chaisson R.E.
        • Raviglione M.
        Latent Mycobacterium tuberculosis infection.
        N Engl J Med. 2015; 372: 2127-2135
        • Golden M.
        • Vikram H.
        Extrapulmonary tuberculosis: an overview.
        Am Fam Physician. 2005; 72: 1761-1768
        • Habaxi K.
        • Wang L.
        • Miao X.
        • Alimasi W.
        • Zhao X.
        • Su J.
        • et al.
        Total knee arthroplasty treatment of active tuberculosis of the knee: a review of 10 cases.
        Eur Rev Med Pharmacol Sci. 2014; 18: 3587-3592
        • Hoffman E.B.
        • Allin J.
        • Campbell J.A.B.
        • Leisegang F.M.
        Tuberculosis of the knee.
        Clin Orthop Relat Res. 2002; 398: 100-106
        • Jiménez-Fuentes M.A.
        • Augé C.M.
        • Gómez M.N.A.
        • Peiró J.S.
        • de Souza Galvao M.L.
        • Maldonado J.
        • et al.
        Screening for active tuberculosis in high-risk groups.
        Int J Tuberc Lung Dis. 2014; 18: 1459-1465
        • Kim H.
        • Park I.
        • Seo S.
        • Han I.
        • Cho H.
        Multifocal infection of mycobacterium other than tuberculosis mimicking a soft tissue tumor of the extremity.
        Orthopedics. 2011; 34: e952-e955
        • Kim Y.H.
        Total knee arthroplasty for tuberculous arthritis.
        J Bone Joint Surg Am. 1988; 70: 1322-1330
        • Klein G.R.
        • Jacquette G.M.
        Prosthetic knee infection in the young immigrant patient–do not forget tuberculosis!.
        J Arthroplasty. 2012; 27: 1414.e1
        • Lange C.
        • Getty P.
        • Morrissey A.
        • George A.
        • Young P.
        • Armitage K.
        Destructive osteoarthritis after delayed diagnosis of tuberculosis.
        Infection. 2002; 30: 46-49
        • Leclere L.E.
        • Sechriest V.F.
        • Holley K.G.
        • Tsukayama D.T.
        Tuberculous arthritis of the knee treated with two-stage total knee arthroplasty. A case report.
        J Bone Joint Surg Am. 2009; 91: 186-191
        • Lee D.-H.
        • Lee D.-K.
        • Lee S.-H.
        • Park J.-H.
        • Kim C.-H.
        • Han S.-B.
        Tuberculous arthritis of the knee joint mimicking pigmented villonodular synovitis.
        Knee Surg Sports Traumatol Arthrosc. 2012; 20: 937-940
        • Lyman S.
        • Lee Y.
        • Franklin P.
        • Li W.
        • Cross M.
        • Padgett D.
        Validation of the KOOS, JR: A Short-form Knee Arthroplasty Outcomes Survey.
        Clin Orthop Relat Res. 2016; 474: 1461-1471
        • Malaviya A.
        • Kotwal P.
        Arthritis associated with tuberculosis.
        Best Pract Res Clin Rheumatol. 2003; 17: 319-343
        • Mancuso J.D.
        • Diffenderfer J.M.
        • Ghassemieh B.J.
        • Horne D.J.
        • Kao T.-C.
        The Prevalence of Latent Tuberculosis Infection in the United States.
        Am J Respir Crit Care Med. 2016; 194: 501-509
        • Marmor M.
        • Parnes N.
        • Dekel S.
        Tuberculosis infection complicating total knee arthroplasty: report of 3 cases and review of the literature.
        J Arthroplasty. 2004; 19: 397-400
        • Marschall J.
        • Evison J.-M.
        • Droz S.
        • Studer U.C.
        • Zimmerli S.
        Disseminated tuberculosis following total knee arthroplasty in an HIV patient.
        Infection. 2008; 36: 274-278
        • Sirlyn Q.
        Knee tuberculosis masquerading as pigmented villonodular synovitis.
        J Res Med Sci. 2014; 1: 19-24
        • Missounga L.
        • Iba-Ba J.
        • Mabika B.
        • Bignoumba E.
        • Nseng I.
        • Madjinou M.
        • et al.
        White swelling of the knee: prevalence, characteristics of osteo-articular tuberculosis followed in rheumatology in Gabon and review of the literature.
        Médecine d'Afrique Noire. 2016; 63: 358-364
        • Mittal R.
        • Trikha V.
        • Rastogi S.
        Tuberculosis of patella.
        Knee. 2006; 13: 54-56
        • Monchal T.
        • Levadoux M.
        • Pellet N.
        • Nguyen M.
        • Ottomani S.
        • Gaillard C.
        • et al.
        Tumeur blanche du poignet: une atteine tuberculeuse rare [White tumor of the wrist: a rare site of tuberculosis involvement].
        Med Trop (Mars). 2007; 67: 134
        • Öztürkmen Y.
        • Üzümcügil O.
        • Karamehmetoğlu M.
        • Leblebici C.
        • Caniklioğlu M.
        Total knee arthroplasty for the management of joint destruction in tuberculous arthritis.
        Knee Surg Sports Traumatol Arthrosc. 2014; 22: 1076-1083
        • Sama J.
        • Chida N.
        • Polan R.
        • Nuzzo J.
        • Page K.
        • Shah M.
        High proportion of extrapulmonary tuberculosis in a low prevalence setting: a retrospective cohort study.
        Public Health. 2016; 138: 101-107
        • Shen H.-l.
        • Xia Y.
        • Li P.
        • Wang J.
        • Han H.
        Arthroscopic operations in knee joint with early-stage tuberculosis.
        Arch Orthop Trauma Surg. 2010; 130: 357-361
        • Su J.-Y.
        • Huang T.-L.
        • Lin S.-Y.
        Total knee arthroplasty in tuberculous arthritis.
        Clin Orthop Relat Res. 1996; 323: 181-187
        • Sun J.
        • Li Q.
        • Gao F.
        • Xiang Z.
        • Huang Q.
        • Li L.
        Application of the Ilizarov technique for knee joint arthrodesis as a treatment for end-stage tuberculosis of the knee.
        BMC Musculoskelet Disord. 2020; 21: 579
        • Tang X.
        • Zhu J.
        • Li Q.
        • Chen G.
        • Fu W.
        • Li J.
        Knee arthrodesis using a unilateral external fixator combined with crossed cannulated screws for the treatment of end-stage tuberculosis of the knee.
        BMC Musculoskelet Disord. 2015; 16: 197
        • Tuli S.M.
        General principles of osteoarticular tuberculosis.
        Clin Orthop Relat Res. 2002; 398: 11-19
        • Wang D.U.
        • Sun X.-T.
        • Zhang C.-F.
        • Fang X.-y.
        • Huang Z.-d.
        • Zheng Q.-C.
        • et al.
        Total Knee Arthroplasty in Patients with Unsuspected Tuberculosis of the Joint: A Report of Four Cases and a Systematic Review of the Literature.
        Orthop Surg. 2020; 12: 1900-1912
        • Watts H.
        • Lifeso R.
        Tuberculosis of bones and joints.
        J Bone Joint Surg Am. 1996; 78: 288-298
        • Wray C.C.
        • Roy S.
        Arthroplasty in tuberculosis of the knee. Two cases of missed diagnosis.
        Acta Orthop Scand. 1987; 58: 296-298
        • Zeng M.
        • Xie J.
        • Wang L.
        • Hu Y.
        Total knee arthroplasty in advanced tuberculous arthritis of the knee.
        Int Orthop. 2016; 40: 1433-1439