Tuberculosis of Hip

2. J.J.M. MEDICAL COLLEGE, DAVANGERE.
DEPARTMENT OF ORTHOPAEDICS
SEMINAR ON
DATE – 06/12/2017
TUBERCULOSIS OF HIP JOINT
Moderators : Presented by :
Dr. Mallikarjuna Reddy(Professor) Dr. Suyash Singhania
Dr. Ravi. G.O(Asst Professor) P.G in Orthopedics

3. CONTENTS
1. History
2. Introduction
3. Risk Factors
4. Pathology and Pathogenesis
5. Clinical features
6. Stages of Tuberculosis of Hip
7. Differential diagnosis
8. Investigation
9. Management
10. References

4. HISTORY
• In India, Rig Veda, Atharva Veda, Charaka
Samhita and Sushruta have mentioned of
Tuberculosis by the name YAKSHAMA in all
its forms.
• Greco-Roman civilization recognized it as
PHTHISIS or Consumption.
• PERCIVAL POTT first described tuberculosis
of the spinal column in 1779.
• ROBERT KOCH discovered
Mycobacterium tuberculosis in 1882.
• LAENNEC discovered the basic microscopic
lesion, the “Tubercle”.

5. INCIDENCE OF TUBERCULOSIS
• 170 per 100,000 in India
• 98 per 100,000 in China
• 48 per 100,000 in Brazil
• 30 per 100,000 in Portugal and
Spain.
• 15 per 100,000 in United
Kingdom
• 4 per 100,000 in USA

6. CURRENT STATUS OF TB IN INDIA
• India has the highest burden of
tuberculosis in world - accounts to 1/5
(20%) of global burden.
• Incidence of new smear positive cases:
75cases/lakh/year.
• Two of every five Indians are infected with
TB bacillus.
• Once infected – 10% life time risk of
developing TB.
• 5% of tubercular patients are HIV positive.

7. RELAVENT ANATOMY OF HIP
• Ball and socket type of synovial joint.
• Considerable part of articular surface of spherical femoral head remains
uncovered.
• Fibro-cartilaginous labrum which is attached to acetabulum, makes the
socket deeper.
• Opening of acetabulum is directed laterally, downwards (300) and forward
(300).
• Femoral neck is directed medially, upward and anteriorly.
• Angle of anteversion in adult is 10-300 and neck shaft angle – 125-1350 .
• The fibrous capsule is strengthen by three ligaments which spiral around
long axis of femoral neck.

8. LIGAMENTS AROUND HIP JOINT
• Iliofemoral ligament (Y shaped
ligament of Bigelow ) arising as
the stem of ‘Y’ from the anterior
inferior iliac spine and adjacent
superior rim of acetabulum.
• Pubofemoral ligament arising
from ilio pubic eminence.
• Ischio femoral ligament is the
weakest of three ligaments and
arises from posterior inferior
margin of acetabulum.

9. INTRODUCTION
• Tuberculosis is one of the oldest diseases known to affect humans.
• It is a chronic granulomatous infectious disease caused by
Mycobacterium tuberculosis.
• Three related organisms which cause tuberculosis-
1) Mycobacterium tuberculosis,
2) Mycobacterium bovis,
3) Mycobacterium africanum.
• Transmission usually taken place through the air borne spread of
droplet nuclei produced by patients with infectious pulmonary
tuberculosis.

10. • Increased incidence has been noted with prevalence of AIDS.
• In India EPTB (extra pulmonary tuberculosis) form 10-15% of all types
of TB.
• Lymph node TB is commonest.
• Osteo-articular TB constitutes 1-3% of which most common type is TB
of Spine which constitutes around 50% .
• TB hip is 2nd most common osteo-articular TB and constitutes 15% of
all cases of osteo-articular TB.
• Other joints commonly involved are Knee joint, Elbow joint, Foot
bones, Hand bones and rarely Shoulder joint.

11. Mycobacterium tuberculosis
• Exists in the form of thin rod with round
ends (2-2.5 M)
• Non motile, Non spore forming, non
capsulated, Strict aerobe.
• Stains by classic Carbol Fuchsin or Ziehl
Neelsen methods.
• Once stained ,the bacilli cannot be
decolorized by acid alcohol- thus called ACID
FAST BACILLI
• Grows in Enriched medium-Widely used is
Lowenstein Jensen Medium without starch.

12. RISK FACTORS
Persons who have been Recently
Infected with TB Bacteria
• Close contacts of a person with
Tuberculosis.
• Health care workers.
• Groups with high rates of TB
transmission, such as I.V drug
users and persons with HIV
infection.
Persons with Medical Conditions that
Weaken the Immune System
• HIV infection
• Diabetes mellitus
• Chronic kidney disease
• Malnutrition
• Immunosuppressants
• Behavioural Factors-alcohol and
smoking

13. PATHOLOGY
• Invariably secondary to primary site elsewhere(Lungs,LN’s of
mediastinum,mesentry, etc)
• Tuberculosis bacilli do not produce any toxin .
• Tissue changes in Tuberculosis are due to host response to several
lipids present in the micro organism in the form of cell mediated
(Type IV) hypersensitivity & Immunity.
• Lipids-
Mycosides – Cord factor – essential for virulence and growth of organism
Glycolipids- present in cell wall of bacilli
• Following infection critical response is in Reticuloendothelial system –
Macrophages and monocytes.

14. • Tuberculosis bacilli are phagocytosed and broken down by
macrophages.
• Lipids are dispersed in cytoplasm of macrophages.
• Cytoplasm becomes – pale and eosinophilic, nucleus becomes
elongated and vesicular.
• This modified macrophages resembles epithelial cells – called
Epitheloid cells.
• Langhans Giant cell:
Formed by fusion of epitheloid cells- comprised of large mass of cytoplasm
containing twenty or more nuclei arranged peripherally as a horse shoe.
Function is to digest and remove necrosed tissue.
Seen only if caseous necrosis has occurred.

16. TUBERCLE/TUBERCULOUS GRANULOMA
• Organised aggregation of epitheloid
cells, langhans giant cells with
central caseous necrosis,
Peripherally surrounded by
fibroblasts, round cells
(lymphocytes) and macrophages.
• It grows by expansion and
coalescence.
• Development of caseous necrosis –
due to interaction of mycobacteria
with activated T-cells as well as
macrophages .

17. PATHOGENESIS
Primary focus
(Active/quiescent, Apparent/latent)
Hematogenous dissemination
2-3 years
Osteo-articular TB

18. Initial focus can start from
1. Acetabular roof
2. Femoral epiphysis
3. Metaphysis(Babcock’s triangle)
4. Greater trochanter (may
involve trochanteric bursa)
5. Rarely Synovial Membrane

19. 1.Lesions of upper
end femur
1.Involves joint
rapidly
1.Destruction of
articular surface of
head & acetabulum
Lesions of
acetabulum(roof)
Joint involvement is
late & by the time
Patient presents
Extensive bone
destruction already
present

20. COLD ABSCESS
• Formed by collection of products of liquefaction and reactive
exudation.
• Composed of
1. Serum leucocytes
2. Caseous material
3. Bone debris
4. Tubercle bacilli
• Migrates following fascial planes, along vessels and nerves.
• Temperature is not raised as in pyogenic infection. Hence “ cold
abscess ” .

21. Cold Abscess(within the joint)
Inferior weaker part of capsule Pelvis
Femoral triangle medial ,lateral and Below the Above the
posterior aspect Levator Ani Levator ani
of thigh
Ischiorectal fossa Inguinal
Region

22. • As the disease progresses head
of femur is partly absorbed &
gets dislocated from acetabulum
onto ilium “WANDERING
ACETABULUM”
• If left untreated, healing is by
absorption & connective tissue
encapsulation, leading to
distortion, deformity and fibrous
ankylosis of joint.

23. FUTURE COURSE OF THE DISEASE
1. May resolve completely.
2. May heal with residual deformities or loss of function.
3. Lesion may be walled off completely and caseous tissue may be
calcified.
4. Low grade chronic fibromatous, granulating & caseating lesion
may persist.
5. May spread locally or systemically.

24. CLINICAL FEATURES
• Insidious onset, runs a chronic course.
• Common in first 3 decades.
• Limp is the earliest and commonest symptom.
• Pain may be absent in early stages.
• Complains of night cries also called as starting pain - rubbing of two
diseased surfaces when the movement occurs due to muscle
relaxation during sleep.
• Constitutional symptom like fever, loss of appetite, loss of weight may
be present.

25. PHYSICAL SIGNS
• General:
Pallor
Lymph node enlargement
Emaciation
Signs of Pulmonary TB
• Gait:
Antalgic / Trendelenburg
• Inspection:
Deformity of limb(as per stage of disease)
Wasting of thigh & gluteal muscles
Swelling around hip(site of cold abscess)

26. • Palpation:
Joint line tenderness
Muscle spasm of lower abdomen & adductors of thigh
Shift of Greater trochanter.
• Movements:
Fixed deformities
Painful range of movements
• Measurements : apparent lengthening/shortening, true shortening
• Due to fixed deformities secondary changes in spine (lordosis,
scoliosis)
• In untreated cases, disease typically follows 4 stages

27. STAGES OF TUBERCULOSIS OF HIP
• Stage I - Synovitis
• Stage II - Early arthritis
• Stage III - Advanced arthritis
• Stage IV - Advanced arthritis with subluxation / dislocation
• Stage V - Terminal or aftermath of arthritis

28. STAGE OF SYNOVITIS
• There is effusion into the joint.
• This demands the hip to be in a position of
maximum capacity i.e. flexion, abduction
and external rotation. (FABER)
• Only extremes of movements are limited
and painful.
• Stage of Apparent Lengthening.
• X ray- soft tissue swelling with or without
Rarefaction of hip bones.
• USG useful to show effusion.
• MRI- shows effusion and bone edema.

29. STAGE OF ARTHRITIS
• Articular cartilage is involved.
• Leads to spasm of powerful
muscle around the hip.
• Flexors and adductors are stronger muscle.
• Hip takes attitudes of flexion,
adduction and internal rotation.(FADIR)
• Stage of Apparent Shortening .
• X ray- Rarefaction, Osteopenia, Bony erosions
in femoral head, acetabulum or both. Slight
diminution in joint space due to decrease in
vertical height of articular cartilage.
• MRI- shows synovial effusion, minimal areas
of bone destruction and osseous edema.

30. STAGE OF ADVANCED ARTHRITIS
• Destruction of articular cartilage and
subchondral bone.
• Flexion, Adduction, Internal rotation
deformity with True and Apparent
Shortening.
• Gross destruction of articular cartilage,
capsule is destroyed, thickened&
contracted.
• X ray – features of early arthritis +
destruction of articular surface. Reduction
in joint space.

32. Advanced Arthritis with Subluxation/Dislocation
• Further destruction of acetabulum,
femoral head, capsule and ligaments.
• Flexion + Adduction + Internal rotation
deformity with gross shortening.
• X ray- gross reduction of Joint space,
Wandering acetabulum + femoral head
may get displaced in the Wandering
acetabulum.
• May show Protrusio Acetabuli.
• May show Mortar and Pestle
appearance.

33. AFTERMATH/TERMINAL STAGE OF ARTHRITIS
• Articular margins are adapted to the deformed position.
• Ankylosis + Subchondral eburnation of bone + Joint
surface becomes irregular ,cobbled ,deformed & devoid
of articular cartilage.
• Features of degenerative arthritis seen.

34. DIFFERENTIAL DIAGNOSIS
• Traumatic Synovitis
• Nonspecific Transient Synovitis
• Rheumatic / rheumatoid disease
• Low grade pyogenic infection
• Perthe’s disease
• Juxta articular disease causing irritation of joint
• Slipped capital femoral epiphyses.
• Avascular necrosis of femoral head

35. SHANMUGASUNDARAM CLASSIFICATION
Shanmugasundaram in 1983 classified the radiological appearances as:
Type 1 - Normal
Type 2 – Travelling/ wandering acetabulum
Type 3 – Dislocating type
Type 4 – Perthes type
Type 5 – Protrusio acetabuli
Type 6 – Atrophic
Type 7 – Mortar & Pestle type

36. 1. Normal Hip type:
Gross appearance and joint space is
normal, radiologically there will be
osteoporosis in continuity.
Treatment is by ATT & skin traction
2. Travelling Acetabulum type
Lesion occupy the roof of the
acetabulum and the narrowing of
the joint space with progressive
upward displacement of head is the
usual course of the disease.

37. 3. Dislocated hip :
• The hip joint is either dislocated on admission
or dislocates posteriorly while undergoing
treatment.
• There will be destruction of it surface, with
cystic lesion in the acetabulum and head.
4. Perthes’ type:
• Children <5yrs
• Thromboembolic phenomenon of selective
vasculature creates changes resembling
perthes disease.
• Capital epiphyses fragmented, dense and
flattened.
• Goes for fibrous ankylosis.

38. 5
5. Protrusio acetabuli :
• Lesion is mainly in the floor of acetabulam.
• Medial displacement of floor from pressure of head
of femur.
• The ossification innominatum gets thinned out at
the level of acetabulam. First and second decade are
the common age group.
6. The Atrophic type
• Marked ‘narrowing’ of joint space.
• Occasionally subchondral lesion are present but the
acetabulam and head of femur ‘retains the contour’.
7. Mortor and Pestle type :
• Severely deformed head and neck in a widened
acetabulum.

39. IMPORTANT OBSERVATIONS
1. TB hip in childhood (growing period)
may cause chronic hyperaemia
which will lead to enlargement of
femoral head epiphysis and
metaphysis leading to COXA
MAGNA.
2. Thromboembolic phenomena of
selective terminal vasculature create
Perthe’s like changes and reduced blood
supply due to effusion (tamponade
effect) causes decrease size of femoral
head and neck – COXA BREVA.

40. 3. Restricted growth of femoral capital epiphysis with normal growth
of trochanteric growth plate leads to – COXA VARA.
4) Restricted growth of trochanteric physis with normal growth of
femoral epiphysis lead to - COXA VALGA.

41. 5. A triad of radiological abnormalities
(Phemister Triad)
1. periarticular osteoporosis
2.peripherally located osseous erosion
3.gradual diminution of joint space
6. Occasionally, wedge-shaped areas of
necrosis(kissing sequestra) in joint
margin. These marginal erosions
may simulate Rheumatoid Arthritis.

42. INVESTIGATIONS
1. Haematological
2. Bacteriological
3. Serological
4. Histology
5. Molecular
6. Radiological
7. Synovial fluid aspiration
8. Aspiration of cold abscess for microbiology
9. Synovial Biopsy

43. HAEMATOLOGICAL
• Hb%- Anaemia
• TC — Increased lymphocytes (lymphocytosis)
• ESR - Raised (Active stage)
• Lymphocyte : Monocyte ratio
5:1 is favorable —High resistance
<5:1 - poor prognosis
• CRP — C-Reactive protein

44. BACTERIOLOGICAL DIAGNOSIS
• Specimen stained for AFB & C/S
• Stains used: - ZIEHL NEELSEN stain
Auramine Orange fluorescence
• Media used for growth: Lowenstein- Jensen
• Conventional AFB C/S – 4wks
- requires live organism
- long incubation period
- low sensitivity in patients already on ATT
• Newer rapid culture tech- BACTEC

45. BACTEC :
• Radiometric culture system
• Detects Mycobacteria as early as 7-14 days
• Based on release of radiolabelled CO2 from the growth of
Mycobacteria in selective Liquid media using C14 labelled
substrate.

46. SEROLOGY
• IgM – diagnostic of activity of the disease
• IgG – diagnostic of chronic/healed disease
- levels remain high even after fulltreatment
• ELISA antibody values are dependent on
- time of taking sample
- state / phase of the disease
• Antibody titres do not correlate with recovery status of thepatient.

47. MOLECULAR DIAGNOSIS
• PCR – single test which amplifies the
genome even if a single organism is present
• Ideal for detection of paucibacillary TB case
• Many target genes of Mycobacteria
• 16sr RNA – used as target sequence as
it is universally present
decreases false negative

48. • Synovial fluid aspiration
AFB positive in 10 – 20% of cases
Cultures positive in 50% of cases
• Synovial Biopsy
More reliable
Cultures positive in 80% cases
Histology : granulomatous inflammation

49. RADIOLOGICAL DIAGNOSIS
• X-Rays
1. Chest X ray PA view
2. X ray of affected joint
• USG
• CT – Scan
• MRI

50. MANTOUX TEST
• Screening Test
• Purified protein derivative (PPD) of Tuberculin (Antigenic culture
extract) injected intradermally 0.1ml into Volar aspect of Left
Forearm
• Read after 48-72 hours
• Longest transverse diameter
• More than 10mm Positive
• 6-10 mm Equivocal Response
• Less than 6mm Negative

51. PROGNOSIS
• With the advent of modern chemotherapeutic agents the
intervention at early stages with combination of surgical management
determines the prognosis.
• Before irreversible change have taken place in cartilage a good result
can be expected from conservative management.
• When head is affected the result is always doubtful and if there is
much bone destruction ankylosis in a good position is the limit of
cure.

52. MANAGEMENT
• The Aim of management is to obtain a painless, symptom free and
stable but freely mobile joint with the patient having a normal gait
without limp, deformity or shortening.
• Treatment includes
1. General
2. Chemotherapy
3. Local treatment

53. TREATMENT
• GENERAL TREATMENT
Liberal diet, fresh air, sunshine, education and occupation.
• CHEMOTHERAPY
• Chemotherapy forms the basis of treatment in all cases and must be started
immediately once the diagnosis is made.
• The problem lies deciding upon appropriate duration of chemotherapy.
• Prevailing practice of extending treatment till radiological evidence of healing
is complete, may be unnecessary.

54. • Minimum of 6 months is a must but some prefer 9 months regime.
Both 6 and 9 months regime appear to give acceptable relapse rates
of within 2%.
• Except in pediatric cases, relapses are not drastically improved by
extending treatment to 12 months.
• Prolonged treatment
• If surgical debridement is indicated but cannot be done.
• Co-existent HIV/AIDS also necessitate prolonged treatment.

55. DRUGS
• First line essential drugs (most effective and necessary component
of therapeutic regimen) :
1. Rifampicin
2. Isoniazid
3. Pyrazinamide
• First line supplemental drugs (highly effective and infrequently
toxic) :
1. Ethambutol
2. Streptomycin
3. Fluoroquinolones – ciprofloxacin and levofloxacin.

56. • Second line (less effective and elicit severe reaction more
frequently) :
1. Para amino salicyclic acid
2. Ethionamide
3. Cycloserine
4. Amikacin
5. Capreomycin
• Newer drugs :
1. Rifapentine
2. Gatifloxacin
3. Moxifloxacin
Principle of treatment of TB has been shifted towards daily regimen
with administration of daily fixed dose combination of first-line ATD as
per appropriate weight bands.

57. REVISED CATEGORIES
TREATMENT GROUPS TYPE OF PATIENT
REGIMEN-FDS
INTENSIVE PHASE CONTINUATION PHASE
NEW(CATEGORY I) •New sputum smear positive
•New sputum smear negative
•New extra‐pulmonary
•New others
2 HRZE 4 HRE
PREVIOUSLY TREATED
(CATEGORY II)
•Smear positive relapse
•Smear positive failure
•Smear positive treatment
after default
•Others
2 HRZES
+
1 HRZE
5 HRE

59. DRUG RESISTANT TUBERCULOSIS
MDR –TB :
• Bacteriological Diagnosis
• If the infecting organism is resistant to both
1. INH and
2. Rifampicin with or without resistance to other ATT
XDR-TB :
• MDR –TB strains resistant to FLUOROQUINOLONES and one of
the Injectables – Kanamycin or Amikacin.

60. Resistant /Therapeutically Refractory case
In clinical orthopaedics –
1. No response to ATT / No progressive healing
2. Increase in Destructive process
3. Continuing discharging sinuses , ulcers
4. New cold abscess appearance
5. Increase in size of existing cold abscess

61. Isolated INH resistance – Rx : Rifampicin
Pyrazinamide 9 months
Ethambutol
Isolated Rifampicin resistance – most common in HIV patients
Rx – several combinations for extended period(up to 18 months)
Isolated Pyrazinamide resistance – Rx: Isoniazid
9 months
Rifampicin

62. Treatment of MDR-TB
• Initial phase – 6 drugs – 6-9 months
• Continuation phase – 4 drugs – 18 months
• 6-9 ( K Lfx Eto C Z E )/18 (Lfx Eto C E)
K – Kanamycin ,
Lfx – Levofloxacin ,
Eto - Ethambutol
C – Clycloserine,
Z – Pyrazinamide,
E - Ethionamide

63. LOCAL TREATMENT
Stages of Synovitis and Early Arthritis
• ATT (multidrug therapy)
• Traction
• Palpable cold abscess may be aspirated with instillation of streptomycin
with or without isoniazid.
• Active assisted movements of hip started as soon as pain has subsided.
• Hip mobilization exercises every hour (when patient is awake) within limits
of tolerable pain.
• With traction : patient progressively encouraged to sit, touch his forehead
to the knee, sitting in squatting position and putting thigh in abduction and
external rotation.

64. TRACTION
• Prevents / Corrects the deformity
• Rest to the part
• Relieves muscle spasm
• Maintains joint space
• Minimises development of migration of acetabulum
• B/L traction – if abduction deformity, to stabilise the pelvis

65. • After 4-6 months patient is permitted for ambulation with suitable
caliper and crutches.
• 12 week non weight bearing, followed by
• 12 week partial weight bearing
• Nearly 12 months after onset of treatment – crutches / caliper
discarded.
• Unprotected weight bearing – usually 18-24 months later.
• Newer studies- weight bearing whenever tolerable.
• If response to conservative treatment is unfavorable, synovectomy
and debridement of joint performed.

66. ADVANCED ARTHRITIS
• Usual outcome is gross fibrous ankylosis.
• Traction and exercises help to overcome the deformities.
• Once gross ankylosis is anticipated, the limb should be immobilized
with help of plaster hip spica for about 6-9 months.
• Ideal position in adults is
neutral between abduction and adduction;
5-10 degree of external rotation and
flexion depending upon age (between 10 degree in children and 30 degree in
adult).
• After 6 month partial weight bearing is started and later with crutches
/ with caliper for 2 years

67. ROLE OF SURGERY
Indications:
• To establish diagnosis by obtaining tissue culture
• Surgery as a therapeutic measure
• Joint debridement and clearance in moderately involved cases.
• Excision arthroplasty or arthrodesis
• Very rarely total hip replacement.
• If response to non-operative treatment is unfavorable, then go for
synovectomy or Debridement.

68. IN CHILDREN
• The deformity and subluxation / dislocation is corrected or minimized
by employing traction or with plaster under G.A. with or without
adductor tenotomy.
• Failure to achieve correction of gross deformities and minimization of
subluxation / dislocation warrants open arthrotomy, synovectomy and
debridement of the joint.
• Arthrodesis / excisional arthroplasty differed till completion of growth
potential. Disease with gross deformity require an extra articular
corrective osteotomy to make them walk better till skeletal maturity.

69. SYNOVECTOMY
• Hypertrophied synovium from inner surface of capsule and from
synovial reflections near the acetabular rim and femoral neck are
separated.
• Diseased and thickened capsule is excised.
• Diseased synovium from the retinacular reflections on femoral head
gently curreted.
• Appropriate rotations of hip joint permit adequate synovectomy from
deeper parts of hip joint without deliberately dislocating hip joint

70. JOINT DEBRIDEMENT
In addition to synovectomy, Remove
• the destroyed areas of femoral head & neck and in the acetabulum.
• Loosened pieces of articular cartilage, sequestra, granulation tissue
and loose bodies / debris within the joint should be removed.
• The diseased thickened capsule may also require to be excised
{ Synovectomy and joint debridement can be satisfactorily carried out
without dislocating the hip joint. Internal rotation and External rotation
provide access to deeper parts of joint cavity. }

71. OSTEOTOMY
• Sound ankylosis in bad position
require upper femoral corrective
osteotomy.
• Sometimes unsound (fibrous
painful) ankylosis in bad position
becomes an osseous fusion (sound
painless) by a high femoral
corrective osteotomy.
• This extra articular procedure can
be done at any age.
• Ideal site for corrective osteotomy
is as near the deformed joint as
possible.

72. ARTHRODESIS
• Success of chemotherapy has almost eliminated the absolute
indications for surgical fusion of hip joint.
• Surgery deferred till the growth potential of proximal femur has been
completed.
• Consider in cases of
• Failure of conservative treatment (after 1 year)
• Relapse, especially recurrence of pain and deformity after conservative
treatment.
• Certain destruction lesions. Ex : formation of sequestra in head or neck of
femur or acetabulum.

73. TYPES OF ARTHRODESIS
1. Intraarticular
2. Extraarticular – ischio-femoral and ilio-femoral
3. Combined (pan articular)
Best Position for Arthrodesis :
1. 300of flexion (depending upon age)
2. No abduction or adduction (in adults)
3. 5 to 100 of external rotation
4. The position of flexion – 10 for each year of life up to 200 then, a little
more is suggested.
This surgery is best suited for young active people and for manual laborer.

74. INTRAARTICULAR ARTHRODESIS
• Performed if disease is active, painful and fibrous
ankylosis present
• Permits
- To obtain tissue for HPE
- Exploration of joint
- Excision of diseased tissues
- Curettage of juxta articular infected cavities
- Supplementation of bone grafts to obtain fusion.

75. Operative Procedure for IA Arthrodesis
• Standard anterolateral/iliofemoral approach
• Grossly diseased capsule, synovium removed
• Joint dislocated carefully
• Excise cartilage, subchondral bone from femoral head and acetabulum
down to cancellous bone
• Reposition the rawed head into freshened acetabular cavity,
• Place cancellous bone graft all around the joint

76. • Keep the joint in best functional position and insert 2-3 long
steinmann pins from base of Greater trochanter to femoral neck and
head, going into acetabulum.
• Apply hip spica
Post Operative Regimen
• Steinman pin removal after 6 to 8 weeks
• Gradual weight bearing with POP on, is started using crutches
• Immobilisation and weight bearing continued for 4-6 months until
radiological evidence of bone fusion.

77. ABBOTT And LUCASArthrodesis
It is a Two stage procedure.
ATT cover is mandatory.
INDICATIONS
• Extensive destruction of head and neck of femur.
• Deficient bone stock due to prior arthroplasty.
• Patients life style prefers a strong, fused and painless hip joint.
• Can be done in the presence of active infection or draining sinuses.

78. First Stage
• Anterior Smith –Peterson approach
• Remove capsule & debride joint
• Remove femur neck stump and denude GT
• Debride GT & acetabulum to bleeding cancellous bone, then place
GT into acetabulum with limb in wide abduction
• 30-90 degrees abduction may be necessary, average -45deg

79. Second Stage
• 4-8 weeks later, osteotomy carried about 5 cm below Lesser
Trochanterthrough lower end of previous incision
• Distal fragment is usually displaced slightly medially to allow a part
of proximal fragment to fit into medullary canal of distal fragment
• Apply hip spica which is removed after consolidation

80. EXTRA ARTICULAR ARTHRODESIS
• An extra-capsular bridge of bone is created between the articulating
bones which acts as a block to movement.
BRITTAIN’S TECHNIQUE/ISCHIO-FEMORAL ARTHRODESIS
• Expose proximal femur laterally, stay out of involved joint capsule
• Perform sub-trochanteric osteotomy angling upwards towards ischium
beneath the involved acetabulum
• With a curette, fashion a hole in the ischium below the involved hip joint
capsule and drive the tibial graft across osteotomy site into ischium.

82. EXCISION ARTHROPLASTY
• GIRDLESTONE – described excision of femoral head, neck, proximal
part of trochanter and acetabular rim for chronic deep seated
infections of hip joint.
• Can be safely carried out in healed / active disease after growth
completion.
• Provides – mobile, painless hip with control of infection, correction
of deformity.

84. • Some degree of SHORTENING, INSTABILITY
• Mean loss of length – 1.5 cm(3.5-5cm)
• Shortening decreased by postoperative prolonged TRACTION in 30-50
degrees of abduction up to 3months
• Instability can be reduced by
• Tectoplasty
• Supra acetabular shelf : full thickness iliac crest is used to
provide shelf at upper margin of acetabulum, to minimize
upward excursion of femur on weight bearing.
• MILCH procedure- pelvic support osteotomy at the level of ischial
tuberosity

86. HIP REPLACEMENT IN TB
• THA in active infection –
controversial due to risk of
reactivation.
• Most authors suggest THA at least 5-
10 years after the last evidence of
active infection.
• Reactivation of infection - 10-30%
cases.
• THA in healed TB Hip is now accepted.
• Majority perform it in the stage of
advanced arthritis or its sequelae,
when joint is unsalvageable.

87. • Wang et al – combination of ATT for at least 2wks preop & for at
least 12months post op.
THA in advanced active TB hip is a safe procedure with symptomatic
relief and functional improvement.
• Sidhu et al – THA in active TB Hip is a safe procedure when
perioperative ATT was used
Adequate surgical debridement and ATT - Key for successful
outcome.
• Kim et al – no difference in reactivation / healing with cemented
/cement less implants.

88. TREATMENT IN CHILDREN
• Synovitis and early arthritis
-ATT
-Traction
-Bed rest
-Supportive
• Management in advanced joint destruction, wandering
acetabulum, or with pathological subluxation is difficult and
controversial.

89. • In children with arthritis –Traction
Failure
Open arthrotomy
Synovectomy
Debridement of diseased joint
• Arthrodesis deferred till growth completion.

90. • In children with healed disease and gross deformity (flexion -30,
Adduction >30, Abduction >10 degrees)
extra articular corrective osteotomy

91. CONCLUSION
• Tuberculosis is a major public health problem in most of the world.
• Early recognition and timely treatment of TB is important in order to
prevent the mortality and morbidity associated with it.
• The Aim of management of TB Hip should be to obtain a painless,
symptom free and stable but freely mobile joint with the patient
having a normal gait without limp, deformity or shortening.

92. References
• Mercer’s Orthopedic Surgery
• Orthopedic Principles and Their Application – Samuel Turek
• TB of Skeletal System – SM Tuli.
• Park – Prevention and Social Medicine
• Internet
1. www.emedline .com
2. www.jbjs.org

93. CONCLUSION