Knee Replacement for Previous TB Knee

Pre-Surgical Evaluation

The American Thoracic Society recommends obtaining chest radiography to identify any evidence of active pulmonary or extrapulmonary TB, even if the patient is asymptomatic, as part of the pre-surgical evaluation for patients with a history of TB knee 1, 2
The Centers for Disease Control and Prevention suggest performing tuberculin skin test (TST) or interferon-gamma release assay (IGRA) to assess for latent TB infection, with IGRA preferred if the patient has received BCG vaccination 2, 3
A reaction ≥5 mm on TST is considered positive in immunosuppressed patients or those with prior TB history, according to the Centers for Disease Control and Prevention 2, 4

The American College of Chest Physicians recommends initiating rifampin 10 mg/kg/day (maximum 600 mg) for 4 months starting 2-3 weeks before surgery and continuing for 3 weeks postoperatively at minimum, as prophylaxis against TB reactivation 3, 7
Alternative prophylaxis regimens include isoniazid 300 mg daily for 9 months, although rifampin has superior completion rates, according to the American Thoracic Society 7, 3

The American Academy of Orthopaedic Surgeons suggests that if active TB is diagnosed, the patient must receive a minimum of 2 months of full multi-drug anti-tuberculous chemotherapy before proceeding with elective knee replacement 1

The Centers for Disease Control and Prevention recommend continuing anti-tuberculous prophylaxis for the full prescribed duration (4 months for rifampin or 9 months for isoniazid) and monitoring for signs of TB reactivation, such as persistent pain, swelling, fever, or systemic symptoms, during the first 2 years postoperatively 7, 3
Monthly clinical monitoring for hepatotoxicity is necessary if on isoniazid or rifampin, including assessment for nausea, vomiting, abdominal pain, jaundice, or dark urine, according to the American College of Chest Physicians 7, 8