Tuberculosis of hip

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tb hip
by dr. hardik pawar

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  • % - PROGNOSIS , C- CHILDREN , A - adult NORMAL 92% , C - Joint space normal Rx – skin traction , ATT TRAVELLING ACETABULUM – 29% , CA – Lesion in roof of aceta. , decreased joint space .50% C – HIP JOINT DISLOCATED POSt. , destruction of surface and cystic lesion in the acetabulum and head80 % . C – Capital epiphysis fragmented , dense , flattened , neck widened , heals by fibrous ankylosis Protrusio
  • % - PROGNOSIS , C- CHILDREN , A - adult NORMAL 92% , C - Joint space normal Rx – skin traction , ATT TRAVELLING ACETABULUM – 29% , CA – Lesion in roof of aceta. , decreased joint space .50% C – HIP JOINT DISLOCATED POSt. , destruction of surface and cystic lesion in the acetabulum and head80 % . C – Capital epiphysis fragmented , dense , flattened , neck widened , heals by fibrous ankylosis Protrusio – CA -
  • TO OBTAIN
  • Active asisted movements should be started as soon as pain is aubsidedHip mobilzation exercises With traction exercise – sittin , After 4-6 month – ambulation wid crutches , 12 wks – non wt bearing , next 12 wks – partial wt bearing After total 12 mnth – full wt bearing
  • ADVANTAGES - permits curratge ,to obtain tissue for HPE, exploration of joint , excision of diseased tissue Iliofemoral – easy in ABDUCTION Ishiofemoral – EASY IN ADDUCTION
  • Indication – extensive femoral head destruction – ABSENCE HEAD, deficient bone stock , Strong , fused , painless hip , BOSWORTH TECH ,.- FEMORO ISCHIAL ARTHRODESIS
  • Tuberculosis of hip

    1. 1. TUBERCULOSIS OF HIP DR. HARDIK PAWAR CARE HOSPITALS
    2. 2. INTRODUCTION • • • • • • • Oldest disease of human beings Chronic granulomatous infectious disease EPTB – 10-15 % Bone and joint – 1-3 % Hip joint 2nd most common M>F Age group – 20 -30 years
    3. 3. HISTORICAL ASPECTS  Robert Koch discovered Mycobacterium tuberculosis in 1882.
    4. 4. PATHOLOGY CAUSATIVE ORGANISM Mycobacterium tuberculosis.  SIZE – 3x0.3 um  Gram positive AFB `  Hematogenous dissemination from primary focus  Bone & joints TB develop generally 2-3 yrs after the primary focus 
    5. 5. PATHOLOGY 1. TB bacilli phagocytosed by mononuclear cells 2. Epitheloid cell formation 3.Langhans giant cell formed by fusion epitheliod cells. Formed only if caseation necrosis has occurred
    6. 6. PATHOLOGY 4.Lymphocytes form a ring around the lesion 5.Tubercle formation   Epitheloid cells-characteristic of TB. Presence of caseation necrosis almost diagnostic of TB
    7. 7. PATHOGENESIS Caseous exudative type • more in children • more destruction • more exudation • abscess formation. Granular proliferative type • more in adults • less destructive • insidious onset/course • Cellular proliferation
    8. 8. Sites of Hip TB • • • • Acetabular roof - MC Epiphysis Neck/metaphysis Greater trochanter
    9. 9. Disease course • Initiation of infection • Joint involvement • rapid destruction • cold abscess »tracks to femoral triangle ,thigh, ischiorectal fossa, inguinal region • Joint Distortion , deformity , ankylosis
    10. 10. Clinical features • Insidious onset • Chronic course • Commonly associated with constitutional symptoms • Limp or lameness – earliest and commonest sign , antalgic gait • Pain - absent in early stage • Night cries • Decreased ROM
    11. 11. Cont. • • • • • Fullness around the hip – cold abscess Deformity - depending on the stage Wasting of the thigh and gluteal muscle Limb length discrepency Due to fixed deformity Secondary chages – lordosis , scoliosis ,
    12. 12. Clinicoradiological staging 1. Stage of synovitis : • Irritable hip , painful movements • Flexion , abduction , external rotation . (FABER ) apparent lenghening. • X-RAY – soft tissue swelling , haziness of articular margins & rarefaction • USG – soft tissue swelling • MRI – synovial effusion • Biopsy – can be done for confirmation
    13. 13. • • • • 2. Stage of early arthritis : Destruction of articular cartilage Spasm of adductors , flexors + wasting Flexion , adduction , internal roatation (FADIR) , Apparent shortening • ↓sed ROM • X-RAY – osteopenia , erosion of articular margins , ↓ joint space • MRI - synovial effusion , edema , minimal bone destruction
    14. 14. • • • • • • 3. Stage of advanced arthritis : Further destruction of joint True shortening > 1 cm Muscle wasting Decrease in ROM X RAY - further decrease in joint space.
    15. 15. • 4. Advanced arthritis with subluxation / dislocation : • Furhter destruction of acetabulum , head , capsule and ligaments. • Gross restriction of ROM • Head – upwards and posteriorly • Wandering / migrating acetabulum • Mortle & pestle appearance • Reduced joint space
    16. 16. Radiograph showing a ‘travelling’ or ‘wandering’ right hip
    17. 17. Radiograph of the LEFT hip showing the ‘mortar-and-pestle’ type lesion
    18. 18. CLINICO RADIO LOGICAL CLASSIFICATION
    19. 19. 6 YEAR BOY WITH DISLOCATING TYPE DISEASE
    20. 20. Tuberculous of the Hip. Morphologic changes “protrusio” type (A) and an “atrophic” type (B).
    21. 21. 2 YEARS BOY WITH PERTHES TYPE DISEASE
    22. 22. COXA MAGNA
    23. 23. MANAGEMENT
    24. 24. INVESTIGATIONS          CBC ESR MANTOUX TEST TB ELISA IMAGING : X RAY – HIP SYNOVIAL BIOPSY SMEAR , CULTURE AND GUINEA PIG INOCULATION MRI - EFFUSION , SYNOVIAL THICKENING , JUXTRA ARTICULAR OSTEOPENIA PCR – RT PCR , NESTED PCR
    25. 25. • X – RAY FINDINGS : Periarticular osteopenia Soft tissue swelling Minimal periostel reaction Joint space narrowing Subchondral cyst Subchondral erosion
    26. 26. INVESTIGATIONS  Sputum examination : for AFB
    27. 27. INVESTIGATIONS  Aspiration of abscess : smears & culture of pus CULTURE=GOLD STANDARD SOLID MEDIA: 3-8 weeks Lowenstein Jensen (egg Based) Middlebrook 7H11(agar based) LIQUID BROTH: 1-3 weeks
    28. 28. INVESTIGATIONS  BACTEC media: for faster culture (within 1-2wks) Bactec 460 Bactec9000MB Bactec mgit960b
    29. 29. AIM OF THE MANAGEMENT PAINLESS SYMPTOM FREE STABLE FREELY MOBLE NORMAL GAIT NO DEFORMITY NO LLD
    30. 30. • • • • GENERAL CHEMOTHERAPY LOCAL TREATMENT ROLE OF SURGERY
    31. 31. GENERAL TREATMENT GOOD DIET FRESH AIR SUNLIGHT EDUCATION OCCUPATION
    32. 32. CHEMOTHERAPY • 6-9 MONTH DURATION • 12 MONTH FOR PEDIATRIC AGE GROUP
    33. 33. • 1st line - HRZES • 2ND Line Capreomycin Kanamycin Ethionamide Cycloserine PAS • Newer drugs : rifapentin , rifabutin , gatifloxacin , moxifloxacin
    34. 34. Bactericidal drugs 1.Isoniazid 2. Rifampicin Dose 5mg/kg 10-15 mg/kg 3. Streptomycin 20mg/kg 4. Pyrazinamide 20-25 mg/kg Bacteriostatic drugs 1. Ethambutol Dose 25mg/kg (x 2mnths) Then 15mg/kg
    35. 35. LOCAL TREATMENT • A) STAGE OF SYNOVITIS AND EARLY ARTHRITIS : ATT TRACTION ASPIRATION OF COLD ABSCESS
    36. 36. • TRACTION : Relieves muscle spasm To give rest to joint Prevents deformity Maintain joint space Minimizes chances of developing migrtaing acetabulum • PROTOCOL :
    37. 37. • B ) STAGE OF ADVANCED ARTHRITIS : Traction Usually gross fibrous ankylosis is out come
    38. 38. Role of surgery • To establish diagnosis • Therapeutic • Failure of conservative treatment
    39. 39. • • • • SYNOVECTOMY DEBRIDEMENT OF JOINT ARTHRODESIS ARTHROPLASTY
    40. 40. ARTHRODESIS • Surgical fusion of joint • INDICATIONS : Failure of conservative Mx Relapse Destructive lesion in head Painful fibrous ankylosis Ankylosis with severe deformity
    41. 41. • TYPES : INTRAARTICULAR EXTRAARTICULAR COMBINED
    42. 42. INTRAARTICULAR • Active disease • Painful fibrous ankylosis • Lower rate of fusion EXTRAARTICULAR • ILIOFEMORAL - HIBBS • ISHIO FEMORAL BRITTAIN’S
    43. 43. • ABOTT LUCAS TECHNIQUE : 2 STAGE PROCEDURE 1ST – Arthrodesis in wide abduction 2nd – subtrochantric osteotomy to repostion limb
    44. 44. • BEST POSITION : 30 DEGREES OF FLEXION 5-10 DEGREES OF ER NO ADDUCTION
    45. 45. EXCISION ARTHROPLASTY HEAD , NECK , RPOXIMAL PART OF TROCHANTER AND ACETABULAR RIM EXCISED PAINLESS MOBILE HIP PERMITS SQUATTING BUT INSTABILITY SHORTENING
    46. 46. REPLACEMENT ARTHROPLASTY • EARLY CEMENTLESS THR IN ACTIVE TB PROVIDED PATIENT IS ADMINISTERED ATT AND THOROUGH DEBRIDEMENT Of DISEASED TISSUE IS DONE. • ( ACCORDING TO RECENT AUTHORS ) • Cemented - Hardinge et al. 1979 - Kim et al. 1988 • Uncemented - Eskola et al. 1988 - Caparros et al. 1999 - Yoon et al. 2001
    47. 47. • Normal hip type tuberculosis lesion of left hip (a, b). Triple chemotherapy for 12 months and bed rest was given. The tuberculosis lesion had healed without joint damage and sequelae (c)
    48. 48. Perthes type hip epiphysio-metaphyseal tuberculosis of the left proximal femur (a, b). After joint debridement, the child was immobilized with cast for 6 weeks under cover of triple chemotherapy (12 months). Tuberculosis healed without joint destruction, though residual coxa magna deformity was present (c)
    49. 49. Atrophic type tuberculosis of hip in a 11-year-old girl. There is slight joint space narrowing of left hip (a). After synovectomy chemotherapy for 12 months was given (b, c, d). Tuberculosis healed (3 years followup) though atrophic head and neck are seen (d)
    50. 50. REFERENCES 1. Campbell JA, Hoffman EB. Tuberculosis of the hip in children. J Bone Joint Surg Br 1995;77:319-26. 2. Shanmugasundaram TK. A clinicoradiological classification of tuberculosis of the hip. In: Shanmugasundaram TK (editor). Current concepts in bone and joint tuberculosis. Madras, India: Proceedings of Combined Congress of International Bone and Joint Tuberculosis Club and the Indian Orthop Assoc;1983. P. 60. 3. Moon MS, Kim SS, Lee SR, Moon YW, Moon JL, Moon SI. Tuberculosis of the hip in children: A retrospective analysis. Ind J Orthop 2012;46: 91-99.
    51. 51. • 4. Eskola A, Santavirta S, Konttinen YT, Tallroth K, Hoikka V, Lindholm ST. Cementless total replacement for old tuberculosis of the hip. J Bone Joint Surg (Br) 1988;70:603– 606. • 5. Yoon TR, Rowe SM, Santosa SB, Jung ST, Seon JK. Immediate cementless total hip arthroplasty for the treatment of active tuberculosis. J Arthroplasty. 2005;20:923– 926. doi: 10.1016/j.arth.2004.08.002.
    52. 52. THANK YOU

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