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Mirna Phandu

Functional outcome on surgical treatment for lower extremity tuberculosis arthritis at Cipto Mangunkusumo Hospital, Jakarta. Mirna Phandu. Introduction. Backgrounds . Tuberculosis infection  main health problems Worlds and developing country Indonesia : WHO 2009 1,2

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Mirna Phandu

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  1. Functional outcome on surgical treatment for lower extremity tuberculosis arthritis at CiptoMangunkusumo Hospital, Jakarta MirnaPhandu

  2. Introduction

  3. Backgrounds • Tuberculosis infection  main health problems Worlds and developing country • Indonesia : WHO 2009 1,2 • Incidence rate 228 per 100.000 • Every age group • Osteoarticular tuberculosis : 3 • 35% from extrapulmonal tuberculosis • (1).WHO regional office for south-east asia. Tuberculosis in South-East Asia Country Profiles Indonesia [document on the internet]. WHO 2007 ; diperbaharuitanggal 15 maret 2009 [diunduh 30 november 2011] tersediadarihttp://www.searo.who.int/en/section10/section2097.htm • (2). Subdit TB Depkes RI. LaporanSubdit TB Depkes RI 2009. [document in the internet]. Depkes 2009 ; diperbaharuitanggalmaret 2010 [diunduh 30 november 2011] • Golden MP, MD, Vikram HR, MD. Extrapulmonary Tuberculosis. An overview. Am Fam Physician. 2005 [diunduh 30 November 2011]; 72 (3):1761-8. Tersediadariwww.Aafp.org/afp

  4. Tuberculosis Arthritis • In every joint : especially weight bearing joint 4,5 • Hip, sacroilliac, knee, costae, shoulder, ankle, elbow and wrist 4,5 • Treatment : 6 • Chemotherapy • Orthopedic  immobilization, surgical and physical therapy • Choice of treatment and expected outcome  classification 7 • 4) l-SayyadMJ, Abumunaser LA. Tuberculous arthritis revisited as a forgotten cause of monoarticular arthritis. Annals of Saudi Medicine. 2011 [diunduh 30 november 2011]; 31(4): 398–401. Tersediadari : http://web.ebscohost.com/ehost/ • 5) Salter RB, MD, Johnson EP. Text book of Disorders and Injuries of the Musculoskeletal System. Edisi 3. Maryland USA: Lippincott Williams & Wilkins; 1999. Hlm 226-31. • 6) Martini M. Tuberculosis of the Bones and Joints. Germany : Springer – Verlag; 1988 • 7) Spiegel DA, MD, Singh GK, MD, Banskota AK, MD. Tuberculosis of the Musculoskeletal System. Techniques in Orthopaedics®. 2005 [diunduh 30 November 2011]; 20(2):167–178. Tersediadarihttp://web.ebscohost.com/ehost/

  5. FUNCTIONAL OUTCOME FOR SURGICAL TREATMENT OF LOWER EXTRIMITY ARTHRITIS TUBERCULOSIS AT CIPTOMANGUNKUSUMO HOSPITAL JAKARTA Functional outcome instrument  to improve care. Use of validated instruments in daily clinical practice and by modifying treatment protocols on the basis of the results. 8 Arthritis Tuberculosis  surgical treatment (in Indonesia)  no study is available • PoolmanRW, Swiontkowski MF, Fairbank JCT, Schemitsch EH, Sprague, S, de Vet HCW. Outcome Instruments: Rationale for Their Use. The Journal of bone and joint Surgery. 2009 [diunduh 30 november 2011]; 91(3): 41-9. Tersediadarihttp://www.JBJS.org/

  6. Research QUESTION Relation between types of joint involved to post operative functional outcome Relation between arthritis tuberculosis classification to post operative functional outcome Relation between types of surgical treatment to post operative functional outcome Relation between age at surgery to post operative functional outcome

  7. AIMS find post operative functional outcome on lower extremity arthritis tuberculosis after surgery

  8. Literature review

  9. Healthy joint Infection by M. tuberculosis through direct route or hematogen bone & synovium Dormant lesion • Age • General condition • Secondary infection • Socio economy condition Reactivation tuberculosis arthritis Stage I-V • Chemotheraphy • Rest • ROM exercise • Splinting • Synovectomy • Osteotomy • Soft tissue release • Arthrodesis • Arthroplasty • Age • Sex • Time after the operation Joint function Healed with near normal function 50-70-% mobility Stable & Painless joint Theory diagram

  10. Lower extremity Tuberculosis arthritis • Hip • Knee • Ankle and foot Conservative • Chemotherapy • Rest • ROM • Splinting Surgery • Debridement & Synovectomy • Soft tissue procedure • Arthrodesis • Arthroplasty Joint destruction Stage I-V • Age • Sex • Joint location • Lung Tuberculosis • Time after the surgery Functional outcome • LEFS : Lower Extremity Functional Scale • HHS : Harris Hip score • KSS : Knee Society Score • FADI : Foot and Ankle Disability index Concepts diagram

  11. Methods

  12. Sampling 61 2008-2012 : 23 pt with lower extremity tuberculosis  Total Sampling

  13. Identification of potential subject : patients that undergo surgery due to lower extremity tuberculosis arthritis between 2008-2012 from RSCM medical record • Consecutive sampling • From medical records Study protocol Informed consent Not agree Agree Exclusion criteria Inclusion criteria Data collection : diagnosis, previous management from medical records Grouping of samples according the involved joints Patients fill in the functional outcome form that corresponded to the joint affected by tuberculosis arthritis

  14. Operational definition • Functional outcome 37 : functional outcome score based on orthopedic instruments score that are widely used and already validated. • Lower Extremity Functional Scale (LEFS) for lower limb • Harris Hip score (HHS) for hip joint • Knee Society Score (KSS) for knee joint • Foot and Ankle Disability Index (FADI)for foot and ankle joint • Surgical treatment • Debridement and synovectomy : resection of the diseased tissue including synovial membran • Arthrodesis : fusing the joint by producing bony union across it • Arthroplasty : a reconstructive operation designed to regain or maintain motion in chronically painful joint by means of altering or replacing one or both joint surfaces • Arthritis tuberculosis : infection to the joint that was caused by Mycobacterium tuberculosis, with diagnosis based on clinical, radiological and positive culture result.10 • Adult : more than 15 y.o • Arthritis tuberculosis classification  staged according to Tuli’s classification 11 • Time after the operation : Time in months since the operation until sampling time • Joint : for this research, joints are including all joints on lower

  15. Data analysis • Data analysis : SPSS for Windows® version 20 • Data would be presented in table, pictures and graphics

  16. Results

  17. 7 patients can’t be contacted 6 pt have involvement > 1 joint Total 22 joints

  18. Patient’s characteristic

  19. Surgical therapy Surgical therapy

  20. 6 mo after surgery Before surgery Last followup (+) effects of surgical procedure on lower extremity arthritis tuberculosis (p<0.001) 6 mo after surgery Last followup Before surgery (p<0.001)

  21. AGE r -.295, p 0.183; The younger the patient  better functional outcome  No statistical correlation

  22. sex LEFS before surgery LEFS 6mo after surgery Before surgery (p.0.305); 6 mo follow up (p 0.859) Lung TB LEFS before surgery LEFS 6mo after surgery Before surgery (p.0.198); 6 mo follow up (p 0.091)

  23. Time of follow up 0.385, p0.077 longer follow up  better functional outcome No statistical meaning

  24. Joint involvement 6 mo after surgery Before surgery Last followup No significant difference Small and varies sample in each group Different management preference for each joint

  25. A B C D Cases no.6 38thy.o female w/ left coxitis tuberculosis. A,B,C before, 6 moand 18 mo after THA.

  26. Classification & functional outcome • Less severe arthritis tuberculosis would have better functional outcome post surgery • Only involved late stage tuberculosis arthritis

  27. Surgical treatment – functional outcome Uji post-hoc Mann-whitney Debridement & sinovektomi vs Soft tissue procedure p0.151; Debridement & sinovektomi vs Artrodesis p0.012; Debridement & sinovektomi vs artroplasti p0.549; Soft tissue procedure vs artrodesis p 0.552; Soft tissue procedure s artroplasti p 0.134; artrodesis vs artroplasti p 0.045

  28. Conclusion

  29. No significant difference between types of joint involved to post operative functional outcome before or after surgery • Less severe arthritis tuberculosis classification have better post operative functional outcome • On the first 6 months after surgery no significant relation between types of surgical treatment to post operative functional outcome • On the last follow up there’s significant difference between arthrodesis dengan artrhoplasty(p 0.045) • No significant relation between age at surgery to post operative functional outcome • No significant relation between time of follow upand functional outcome,

  30. Suggestion Future study : • Specific study for each joint • Adapted international functional outcome scoring to Indonesian population

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