Brief quick information of TB HIP. introduction , pathophysiology, stages, signs and symptoms, clinical assessment, investigation, XRAY, and management of TB hip joint.

1. Tuberculosis of the Hip
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2. Common Sites
1. Acetabulum
2. Head of femur
3. Neck of femur
4. Greater trochanter

3. Pathology
• Primary TB  dissemination  infection of bones and joints 
chronic granulomatous inflammation with caseous necrosis
a. Proliferative type: Chronic granulomatous inflammation with
extensive fibrosis
b. Exudative type: extensive caseation with limited cellular reaction.
• Intense local hyperemia  demineralization of bone
• Reduced host resistance  cortex eroded  pus reaches sub-
periosteal and soft tissue planes  cold abscess  burst  sinus

4. • Acetabulum/head of femur gets partially absorbed  muscles of hip
pull femur head upwards  head dislocates from acetabulum 
ilium (wandering acetabulum).
• It can also form a cold abscess (pelvic abscess)

5. Clinical features
• Child looks apathetic and pale with loss of appetite. (precedes local
symptoms)
• Stiff hip, initially at rest, eventually constant.
• Limp
• Night cries and starting pain, maybe referred to knee
• Cold abscess may burst  discharging sinus

6. On examination
• GAIT: Stiff hip gait initially  painful gait
• Child stands with compensatory exaggerated lumbar lordosis.
• Thigh and gluteal muscle wasting
• Movements restricted in all directions, due to surrounding muscle
spasm, and ankyloses.
• Head of femur felt in gluteal region
• Telescopy test done to assess the instability of the head of femur.
• Deformity (explained in stages)

7. Stages of TB Hip
• Stage 1  Stage of synovitis/ apparent lengthening
• Stage 2  Stage of arthritis/ apparent shortening
• Stage 3  Stage of erosion/ true shortening

8. Stage 1
• Synovitis  Effusion into the joint  flexion, aBduction, external
rotation  pelvis tilts down to compensate for abduction  affected
limb appears longer.

9. Stage 2
• Articular cartilage involved  surrounding muscle spasm  flexion,
aDduction, internal rotation  pelvis tilts up to compensate for
adduction  affected limb appears shorter.

10. Stage 3
• Cartilage destruction  head and/or acetabulum eroded 
subluxation/ dislocation  exaggerared flexion, aDduction, internal
rotation  True shortening.

11. X-Ray
Of pelvis with both hip joints, AP and Lateral view
• Haziness of bones around hip (earliest sign)
• Lytic lesions may be present.
• Reduced joint space due to cartilage destruction
• Irregular outline of articular ends of bone.
• Head of femur on ilium (wandering acetabulum)
• Sclerosis around hip indicates healing

13. Other Investigations
• Chest X ray
• Sputum gram staining
• Mantoux test (in children)
• ESR
• Synovial fluid aspiration
• Histopathological examination of granulation tissue obtained by
biopsy/ curettage.

14. Non-opervative treatment
• Immobilization of hip joint with below knee skin traction.
• ATT for 6-9 months (H- 5mg/kg/day, R- 10mg/kg/day, Z- 25-
30mg/kg/day, E- 15-20mg/kg/day)
• Hip spica
• General care (rest, nutritional rehabilitation, etc)
• Proper positioning of joint and early mobilization to prevent
contractures and regain movement

15. Operative treatment
1. JOINT DEBRIDEMENT
2. GIRDLESTONE ARTHROPLASTY
3. ARTHRODESIS
4. CORRECTIVE OSTEOTOMY
5. TOTAL HIP REPLACEMENT

16. JOINT DEBRIDEMENT
• Open from posterior approach  remove dead cartilage, inflamed
synovium, pus, necrotic tissue  curette any cavity in the head of
femur/ acetabulum  wash with saline  close wound.
• Post-op, keep joint surfaces apart using traction  mobilize when
healed.

17. GIRDLESTONE ARTHROPLASTY
• Open from posterior approach  excise head and neck of femur 
dead necrotic tissue and granulation tissue excised
• Post-op bilateral skeletal traction x4 weeks  mobilize

19. ARTHRODESIS
• The joint is put in the most functional position by surgically knocking
the joint out.

20. CORRECTIVE OSTEOTOMY
• Done at sub-trochanteric level.
• Done when bony ankylosis has occurred.

21. TOTAL HIP REPLACEMENT
• Done in the quiescent stage of TB.

22. Thank you