This document discusses tuberculosis of the hip, including its pathogenesis, clinical features, diagnosis, classification, and management. Some key points: - TB of the hip is usually secondary to a primary lung infection and spreads hematogenously. It presents with limping and referred knee pain. - Stages include synovitis, early arthritis, and advanced arthritis with possible subluxation. Radiographs show osteopenia, erosions, and joint space narrowing. - Treatment involves anti-tubercular drugs, bed rest, traction, and may require synovectomy, arthrodesis, or excision arthroplasty depending on stage and deformity. The goal is to preserve joint function through early diagnosis and

1. INCIDENCE CLINICAL
FEATURES, DIAGNOSIS AND
MANAGEMENT OF
TUBERCULOSIS OF HIP
Dr.Y.Saipram
od

2. Introduction
 Oldest disease of human beings
 Tb hip – 2 nd only to spine
 spine:hip ratio – 10:7
 Osteoarticular TB – 1-3% of all TB cases,of
which TB hip – 15-20%
 M>F
 Age group 20-30yrs

3. Organism
 Mycobacterium tuberculosis
 Gram positive AFB
 Hematogenous dissemination from primary
focus
 Bone and joints TB develop generally 2-3
yrs after primary focus

4. Pathogenesis & Pathology
Primary focus
(Active/quiscent,Apparent/latent)
Hematogenous dissemination 2-3 yrs
Osteoarticular TB

5. PATHOLOGY
 Infection of hip is secondary to some primary
focus either in lungs or mediastinal node or
iliocaecal region and spread to hip by blood
stream.
 Initial focus may start in acetabular roof >
epiphysis ( head ) > Metaphysis or neck (
Babcock triangle ) > greater trochanter .
Rarely the disease may start in synovial
membrane and may remain as synovitis for
months.

6.  When initial focus is acetabular roof -- joint
involvement is late and severity of symptom is
mild – by the time pt. report to hospital
,extensive destruction already present .
 TB of greater trochanter may involve the
trochanteric bursa without involving the hip for
long time .
 As the upper end of femur is entirely
intracapsuler the joint get involve rapidly and
disease become osteoarticular.

8. Clinical features..
 Commonest age : 1st 3 decades
 Limping – earliest, commonest
symptom - Antalgic gait
 Pain – referred to medial aspect of
knee - max towards end of the day
 Deformity
 Fullness around the hip
 Night cries

9. STAGES OF T.B. HIP

10. Synovitis stage..
 Position of max joint capacity –
FABER
 Apparent LENTHENING
 Only extremes of movement are
painful
 DD – Traumatic synovitis
- Nonspecific Transient
Synovitis
- Low grade pyogenic infection
- Perthes disease
- SCFE
 USG repeated at 2-3 wks
 X-Rays: soft tissue
swelling,Rarefaction

11. Early Arthritis stage..
 Articular damage starts.
 Severe muscle spasm-
FADIR.
 Apparent shortening.
 Restriction of movements
in all directions
 Appreciable muscle
wasting
 MRI – synovial effusion
- minimal areas of bone
destruction
- osseous oedema
 X-Rays: OSTEOPENIA,
marginal bony erosions

12. Advanced Arthritis ..
 FADIR
 True shortening
 increase in severity
of symptoms
 Capsule further
destroyed
,thickened &
contracted
 X-Rays :
Destruction of
articular surface
decrease in Joint
space

13. Advanced arthritis with
Subluxation / Dislocation
 With further destruction of
acetabulum, femur head ,capsule &
ligaments the upper end of femur is
displaced upwards & dorsally in the
wandering / migrating acetabulum
leaving its lower part empty & broken
– Pathological dislocation of femur
head
 Movements are grossly restricted

15. CLASSIFICATION -
RADIOLOGICAL APPEARENCE
 Shanmugasundaram in 1983 classified
the radiological appearences as
 1. Type 1 - normal (C)
 2. Type 2 – Travelling/ wandering
acetabulum(C,A)
 3. Type 3 – Dislocating type(C)
 4. Type 4 – Perthes type(C)
 5. Type 5 – Protrusio acetabuli(C,A)
 6. Type 6 – Atrophic(A)
 7. Type 7 – Mortar & Pestle type(C,A)

20. IMPORTANT
OBSERVATIONS
 Childhood TB hip (growing period) chronic
hyperemia would lead to enlargement of
femoral head epiphysis and metaphysis
leading to COXA MAGNA.
 Thromboembolic phenomena of selective
terminal vasculature create Perthe’s like
changes and reduced blood supply due to
effusion (tamponad effect) causing
decrease size of femoral head and neck –
COXA BREVA.

21.  Restricted growth of femoral capital
epiphysis with normal growth of
trochanteric growth plate lead to –
COXA VARA.
 Restricted growth of trochanteric
physis with normal growth of femoral
epiphysis lead to - COXA VALGA.

22.  A triad of radiologic abnormalities (Phemister triad);
– periarticular osteoporosis
– peripherally located osseous erosion
– gradual diminution of joint space suggests the dx of TB
 Occasionally, wedge-shaped areas of necrosis (kissing
sequestra) in joint margin. These marginal erosions may
simulate RA

23.  Close relationship b/w radiological
type & therapeutic outcome:
 1. Normal type - 92% good results
 2. Perthes type - 80% good results
 3. Dislocating type – 50% good results
 4. Travelling acetabulum & Mortar
pestle type - 29% good results

24. Evaluation
 Hematological – ESR,relative lymphocytosis
 Bacteriological –AFB staining & C/S
 Serological – ELISA –serum IgG,IgM
 Histology – HPE for ‘ TUBERCLE ‘
 Molecular – PCR using 16sr RNA
 Clinico –radiological : X-Rays, CT Scan ,MRI,
USG

25.  Synovial fluid aspiration
AFB positive in 10 – 20% of cases
Cultures positive in 50% of cases
 Aspiration of cold abscess for microbiology.
 Synovial Biopsy
More reliable
Cultures positive in 80% cases
Histology : granulomatous
inflammation

26. Molecular diagnosis..
 PCR – single test which amplifies the
genome even if a single organism was
present
• Ideal for detection of paucibacillary
TB case
• Many target genes of Mycobacteria

27. Management..
 Thomas urged that TB should
be treated by rest –which had
to be
‘prolonged, uninterrupted, rigid
and enforced’.

28. Management..
 Early diagnosis , effective chemotherapy –
vital to save the joint
 Depends upon the stage of clinical
presentation
 Rx includes –ATT
- Absolute bed rest
- Traction
-Excision Arthroplasty
- Arthrodesis
-THA

29. Rx – Synovitis stage
 Chemotherapy – ATT
 Bed rest
 Traction
 Mobilisation exercises
 prognosis – very good
 Surgical intervention – usually not
required

30. Rx – Early Arthritis
 Chemotherapy – ATT
 Traction
 Analgesics supplementation
 Non wt bearing ROM exercises
started as permitted
 Synovectomy & joint debridement .
 Passive exercise causes pain,spasm .
Thus avoided .
 Prognosis in general - good

31. Rx – Advanced Arthritis
 All above &
 ARTHROLYSIS –subtotal excision of
pathological contracted fibrous
capsule
- Useful where limitation of movements
is due to FIBROUS ANKYLOSIS
-Aim – To achieve useful ROM
- Posterior capsule undisturbed – vital
blood supply

32. Rx – Advanced arthritis with
subluxation / dislocation
 Conservative traction regimen
 If sound ankylosis ,in bad position –
upper femoral corrective osteotomy
 Excision arthroplasty
 Arthrodesis
 Hip replacement

33.  In advanced arthritis usual
outcomeFIBROUS ANKYLOSIS
 Once fibrous ankylosis – anticipated /
accepted – limb is immobilised in HIP
SPICA for 4-6 months
 Ideal position for ankylosis : - Neutral
position b/w abduction & adduction
- 5-10 deg of external rotation
- Flexion depending upon age
:children- 10 deg
adults – 30 deg

34. 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

35.  After 4-6 months of Rx – Ambulation with
crutches / orthosis
 Ambulation : - 1 st 12 wks – non weight
bearing
- 2 nd 12 wks – partial weight
bearing
 Unprotected wt bearing – 18-24 months
after onset of Rx

36. Arthrodesis..
 Offered only for pt > 18yrs age
 Types :
 1.Intra articular
 2.Extra articular
– if Adduction – Ischio
femoral
- if abduction – Ilio femoral
 3.Combined intra –extra articular

37.  During extra articular arthrodesis ,upper
femoral corrective osteotomy can also be
performed – brings limb into functional
position.
 Intraarticular arthrodesis permits
- Exploration of joint
- Excision of diseased tissue
- Curretage of juxta articular infected tissue

39. Disadvantages of arthrodesis
 Early development of degenerative osteo
arthrosis in LS spine,ipsilateral knee,
contralateral hip
 Activities max limited after fusion
- bending,sitting on floor, cross legged sitting
,
- Squatting,kneeling,bicycling
- Requires 30% more energy for ambulation
 Thus no pt would accept a fused joint

40. Excision arthroplasty..
 • GIRDLESTONE – described excision of
femoral head,neck,proximal part of
trochanter & 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

42.  Some degree of SHORTENING,
INSTABILITY
 Mean loss of length – 1.5 cm
 Shortening can be decreased by post op
prolonged TRACTION in 30-50 deg of
abduction up to 3months •

43. Hip replacement in TB ..
 THA in active infection – controversial due
to risk of reactivation
 Most authors suggest THA atleast 5-10 yrs
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 / its sequelae, when joint is
unsalvageable

44. Rx in chidren..
 Synovitis & early arthritis – ATT
- Traction
- bed rest
- supportive Rx
 Management in advanced joint
destruction , wandering acetabulum,or
with pathological subluxation is difficult
& controversial.

45.  In children with arthritis –
 Traction
failure
Open arthrotomy
Synovectomy
Debridement of diseased joint
 Arthrodesis deferred till growth
completion

46.  In children with healed disease &
gross deformity ,(flexion -30,Adduction
>30, Abduction >10 deg)
 extra articular corrective osteotomy