2. Introduction
Tuberculosis is one of the oldest disease known to affect humans
Chronic granulomatous disease caused by Mycobacterium tuberculosis, others are
M.bovis & M.africanum
Extrapulmonary TB (EPTB) is 10-15% of all types of TB in India
Lymphnode TB is commonest of it.
While osteoarticular TB is 1-3% of it.
out of which most common is Spinal TB (50%) & TB hip is 2nd most common (15%)
Other joints are knee, elbow, foot & hand joints, shoulder (rare).
3. Risk Factors
Persons who have been recently infected with TB bacteria:
Close contacts of person with TB
Health care workers
i.v. drug users & persons with HIV infection
Persons with medical conditions that weaken the immune system:
HIV infection
DM
CKD
Malnutrition
Immunosuppresants
Alcohol& smoking
4. Pathology
All tissue changes in tuberculosis are due to cell mediated (type IV) hypersensitivity
reaction of host to several lipids of micro organism
TB bacilli are phagocytosed by macrophages
Epitheloid calls formation
Langhans giant calls formed by fusion of epitheloid cells
Lipids are dispersed in
cytoplasm of macrophages
This modified macrophages
resembles epithelial cells
Lymphocytes forms a ring around lesion Tubercle
5. Pathogenesis
Primary Focus
Haematogenous spread
(2-3 years)
Osteo-articular TB
Caseous Exudative type:
More in Children
More destruction
More exudation
Abscess & sinus formation
common
Constitutional symptoms & signs
of inflammation are marked
Granular type:
More in adults
Less destructive
Insidious onset &
course
Abscess is rare
(‘Dry lesion’)
6. Sites of TB Hip
1) Acetabular roof (commonest) – late
joint involvement but presents with
extensive destruction
2) Femoral epiphysis – intracapsular, rapid
joint involvement
3) Neck/metaphysis/Babcock’s triangle
4) Greater trochanter (may involve
trochanteric bursae) – without
involving hip for long time
5) Rarely synovial membrane
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8. Cold abscess
Collection of products of liquefaction and reactive exudation
Composed of serum, leucocytes, caseous material, bone debris, tubercle bacilli
Feels warm but not temperature not raised as pyogenic abscess
If bursts– Sinus/ulcer formation
If formed in ajoint, may present in femoral triangle, ischiorectal fossa, pelvis,
medial/lateral/post. asp of thigh
10. Tubercular sequestra
Following infection, marked hyperemia & severe osteoporosis takes place
Osseous destruction by lysis of bone which is softened & yields under effect of gravity
& muscle action leading to
compression, collapse & deformation of bones.
Necrosis tales place due to ischemic infarction of bone segment
Infection plus infarction thus forms bone sequestrum.
11. Future course of disease
May resolve completely
Heal with residual deformities or loss of function
Lesion may be walled off completely and caseous tissue may be calcified
Low grade chronic fibromatous, granulating & caseating lesion may persist
Infection can spread- contiguous, systemically
12. Clinical Features
Commonly occurs in first 3 decades
Limp is earliest and commonest symptom
Pain may be absent in early stages, referred to medial asp of knee
Night cries
Constitutional symptoms: fever, loss of appetite, loss of weight
13. Physical signs
General:
Pallor
Lymphadinitis
Signs of pulmonary TB
Gait:
Antalgic/Trendelenburg
Inspection:
Swelling around hip (cold abscess)
Deformity of limb according to stage of disease
Wasting of thigh muscles & glutei
14. Palpation:
Joint line tenderness
Muscle spasm- lower abdomen & adductors of thigh
Shift of GT
Movements:
Painful ROM
Fixed deformities
Measurements: Apparent lengthening/shortening, true shortening(acc. to stages
of disease
Due to fixed deformities, secondary changes in spine (lordosis/scoliosis)
15. Stages of TB Hip
Stage I: Synovitis
Juxtaarticular osseous lesion causing ‘irritable hip’
Effusion in hip joint leading to hip in a position of maximum capacity, i.e. Flexion,
ABduction, External Rotation
Stage of ‘apparent lengthening’
Xray- soft tissue swelling, with/without rarefaction articular margins
USG/MRI- effusion in hip joint
16. Stage II: Early Arthritis
Articular cartilage involved
Spasm of muscles around hip (flexors & adductors), leading to
Hip in Flexion, ADduction, Internal Rotation
‘Apparent Shortening’
Xray- Rarefaction, osteopenia, bony erosions in femoral head, acetabulum or both,
diminution in joint space, reduced vertical height of articular cartilage
MRI- synovial effusion, minimal bone destruction
17. Stage III: Advanced Arthritis
Destruction of articular cartilage & subchondral bone
Capsule destroyed, thickened & contracted
Flexion, ADDuction & internal rotation deformity
True & apparent shortening
Xray- early arthritis, destruction of articular surface, reduction in joint space
18. Stage IV: Advanced Arthritis with Subluxation/Dislocation
Further destruction of acetabulum, femoral head, capsule, ligaments
FADIR deformity with ‘Gross Shortening’
Xray- grossly reduced joint space, wandering acetabulum, broken Shenton’s arc
May show ‘protrusio acetabuli’
Or, ‘Mortar & pestle appearance’, due to collapsed neck (coxa breva)
Sometimes destruction of capsule and acetabulum so severe to lead to frank
pathological posterior dislocation
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21. In general, the movements at this stage are grossly restricted
But in some cases with wandering acetabulum, protrusion acetabuli or Mortar &
pestle picture may retain fairly good range of movements for a long time
In certain cases of TB arthritis (stage II, III, IV), the hip may not assume the classical
triple deformity of F-AB-ER instead the deformity may be that of FF-AD-IR due to
destruction of iliofemoral Y ligament!
If limb plastered for longer duration, growth plate around knee may get closed- Flame
Knee
24. ‘Phemister Triad’: Periarticular osteoporosis + peripherally located osseous erosion +
gradual diminution of joint space
Coxa Magna: TB hip in childhood causes chronic hyperemia, leading to enlargement of
femoral head epiphysis & metaphysis
Coxa Breva: Thromboembolic phenomena of terminal vasculature creates Perthe’s like
changes & reduced blood supply due to effusion (remponade effect) decreases size of
head & neck
Coxa Vara: restricted growth of femoral capital epiphysis with normal growth of
trpchanteric growth plate
Coxa Valga: restricted growth of trochanteric growth plate with normal growth of
femoral epiphysis
25. Investigations
Haematological: CBC/ESR/CRP
Bacteriological: ZN stein, BACTEC
Serology: IgM (active disease) IgG (chronic/healed disease)
Molecular diagnosis: PCR- very sensitive thus ideal for paucibacillary TB, highly
efficient, rapid(3 days), differentiate typical from atypical myco but can’t diff live
from dead organism, not confirmative
Synovial fluid: AFB positive in 10-20% cases, culture positive inn 50%
Synovial biopsy: cultures positive in 80%
Radiology: Xray, USG, CT, MRI
Screening test: Montoux & IFN gamma- can diff typical from atypical
26. Management
Aim: obtain painless, symptom free & stable but freely mobile joint with normal gait
without limp, deformity or shortening
Treatment: Chemotherapy
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33. Local Treatment
Stages of Synovitis & Early Arthritis:
ATT
Traction
Aspirate cold abscess with instillation of streptomycin &/or INH
Active assisted hip movement once pain subside
Hip mobilization within limits of tolerable pain
Pt is allowed to sit, touch forehead, squatting
Ambulation with Caliper/crutches after 4-6 months
Non weight bearing 12 weeks
Partial wt bearing next 12 weeks
Unprotected wt bearing- 18-24 months later
34. Advanced Arthritis:
Usual outcome is fibrous ankylosis
If ankylosis is anticipated, limb is immobilized in plaster hip spica for 6-9 months in
neutral position in coronal plane, 5-10 degrees of ER & flexion acc to age (1 deg each
year upto 20 deg) 10 deg in children & 30 deg in adults
After 6 months, partial wt bearing with crutches/caliper for 2 years
35. Role of Surgery
Diagnostic- tissue culture
Therapeutic- joint debridement & clearance
Excision arthroplasty or arthrodesis
Rarely THR
36. Management in Children
Deformity & subluxation/dislocation- corrected with traction or spica with/without
tenotomy (adductor) under GA
Failure to do so, warrants open arthrotomy, synovectomy & debridement
Arthrodesis/excisional arthroplasty avoided till completion of growth potential; if
required extraarticular osteotomy performed to make them walk till maturity
37. Synovectomy & Joint Debridement
Performed without dislocating femoral head
Hypertrophied synovium separated
Thickened capsule excised
Diseased synovium from retinacular reflexions on head is curreted
Destroyed areas of head, neck, acetabulum is removed in debridement!!!
Complications: AVN, SCFE in children, # neck & acetabulum
38. Osteotomy
Sound ankyloses in bad position- upper femoral corrective osteotomy
Extraarticular procedure
Done at any age
Stay as close as possible to deformed joint
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40. Arthrodesis
Deferred till the growth potential of prox. Femur completed
Indicated when, Failure of conservative Rx & Relapse of pain and deformity after
conservative Rx
Best Position: Neutral in coronal plane
5-10 deg. of ER
10-30 deg. Flexion
41. Intraarticular Arthrodesis
Performed in active disease
It allows, to obtain tissue for HPE
Joint exploration
Excision of tissue
Curettage of infected articular cavities
Supplementation of bone grafts
Anterolateral approach
Excise diseased tissues from head acetabulum & juxta articular cavities
Cancellous bone graft placed in large cavities and around joint line
Fix with 2 or 3 Steinmen’s pins, give hip spica for 6-8 weeks, remove pins after that, wt
bearing with spica & with crutched for 4-6 months until radiological fusion
Further protection with crutches for 1 year after spice removed
42. Abbott-Lucas’ technique of fusion of hip
joint
2 stage surgery
Indication:
Deficient stock due to prior arthroplasty
Extensive destruction of head & neck of femur
Pt lifestyle prefers strong, fused, painless hip
Can be done in active infection
Anterior Smith-Peterson approach
Remove capsule
Remove neck stump & denude GT
Debride GT & acetabulum until bleeding cancellous bone
Put GT into acetabulum, close wound, keep limb in 30-90 deg. Abduction
43. After 4-8 weeks, osteotomy 5 cm below LT through lower end of previous incision
Distal fragment displaced slightly medially to allow a part of prox fragment to fit into
medullary canal of distal fragment
Hip spica- removed after sign of fusion
45. Disadvantages:
Early degenerative arthritis of LS spine, ipsilateral knee and contralateral hip
Limited activities
Compensation for fused hip: rotated pelvis & increased flexion of ipsilateral knee
while stance phase
46. Excision Arthroplasty
GIRDLESTONE:
Performed in active/healed disease.
Gives mobile, painless hip with correction of deformity & infection control
Anterior/anterolateral incision
Excise femoral head & neck in line parallel to intertrochanteric line
If joint ankylosed & can’t be dislocated, head & neck removed and 2-4 cm gap should be kept
between trochanter & pelvis
No projecting bone, raw surface cauterized, no soft tissue to be interposed, close wound with
drain
47. Post-op:
Proximal tibial ST pin traction in 30-50 deg. Abduction for 3 months
Active assisted hip & knee started during 1st week
Encourage to squat & in Tailor’s position
Mobilize with crutches/caliper- after 3 months
Walking with stick on contralateral side- after 6-9 months
Average length of shortening- 1.5 cm, prevented by traction upto 3 months
If instability, ‘tectoplasty’
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49. Supra-acetabular shelf: full thickness iliac crest used to provide shelf at upper margin
of acetabulum
Pelvis support osteotomy: Milch-Bacheolar type at level of ischeal tuberosity
50. Hip replacement in TB
THA can be performed 3 years or more after last evidence of active infection
With combination of ATT for at least 2 weeks preop & 12 months postop