complete coverage of the topic including recent advances

1. TB Hip
Mohammed Fawas
Junior resident
Govt. Medical College Kozhikode

2. Mycobacterium TB
• Discovered by Robert Koch 1882
• Also called Koch’s organism
• Slow growing aerobic acid fast obligate pathogen

3. BCG VACCINATION
• Given at birth
• 0.1 ml intradermally
• Proximal to deltoid insertion L forearm
• Wheal 8mm
• Induration 3-4 weeks
• Papule with central nodule 6 weeks
• Superficial ulcer
• Permanent scar 6 months

4. Pathology of osteoarticular TB
• Haematogenous or lymphatic spread
• Lungs, cervical and mediastinal lymph nodes
Mesentery and viscera
• Arterioles
simultaneos involvement of multiple organs
• Batsons plexus of veins

5. • infection starts mainly in the bone
• Rarely in synovial membrane
• Metaphysis in growing bone
• End of long bones in adults
• Articular cartilage of the joint is resistant to infection----
mycobacteria do not produce proteolytic enzymes

6. • Physeal plate penetration
• Inflammatory changes in the subchondral area
• loss of nourishment
• Detachment from bone

7. • SYNOVIAL TB
• Synovial hypertrophy and effusion
• TB granulation tissue(pannus) accumulates at the periphery of articular
cartilage and erodes
• ‘’RICE BODIES’’
• All pathology leads to joint destruction and associated deformities
• “kissing lesion”

8. • TB BACILLI at RETICULOENDOTHELIAL SYSTEM
• Cell mediated immunity activated
• Polymorphs ,monocyte and macrophages
PHAGOCYTOSIS

9. • EPITHELOID CELLS
• Large macrophage with abundant cytoplasm and large
vacuolar nucleus

10. • LANGHANS GIANT CELLS
Caseation necrosis
• Fusion of a number of epitheloid cells
• Large cell with abundant cytoplasm and peripherally arranged
palisading nuclei
• Lymphocytes arranged peripherally
• Removes necrotic debris

13. TUBERCLE
• Soft tubercle hard tubercle
• PATHOLOGICAL TYPES
• Caseous exudative type
Active, destructive
• Granular type
Indolent and less destructive

14. Symptoms and signs
• Low grade fever
• Evening rise of temperature
• Loss of appetite
• Loss of weight
• Anemia
• Tachycardia

15. Local symptoms
• Pain and limping (MC)
• Swelling around hip
• Decreased ROM/ spasm
• Muscle wasting
• Regional lymph node involvement
• Discharging sinus

16. Cold abscess
• Result of products of liquefaction necrosis and reactive exudation
• Contains serum, WBC, caseous materials, bone debris
• Temperature is not raised as in pyogenic infections

17. • Anteriorly femoral triangle
• Medial side of thigh upto knee
• Posteriorly gluteal region
• Pelvic cavity
• Can track down through neurovascular bundle

18. INVESTIGATIONS AND DIAGNOSIS
• X RAY
• Chest PA view
• LOCAL part
Findings appear 4-6 months after infection
Upto 40% demineralisation

19. • joint space reduction, fuzzy joint margins
• Soft tissue shadows
• Localised lytic lesion, para-articular osteoporosis
• Articular margins and cortex HAZY---WASHED OUT APPEARANCE
• Sequestrum
• Periosteal reaction

20. Mantoux test
• SCREENING TEST
Positive if previously sensitised
Also positive in recently vaccinated
• False negative
Miliary TB
High grade fever with exanthema
A/c viral infection
Immunocompromised
Steroid therapy

21. • 5 TU are injected volar aspect of L forearm
• Read after 48-72 hours
• Longest transverse diameter
• More than 10mm----positive
• Less than 6 mm ----negative
• 6-10 mm -----equivocal response

22. USG
• Soft tissue edema
• Useful in TB tenovaginitis
MRI
• X ray changes only after 40% demineralisation
• Bony edema and soft tissue hypertrophy
• Associated pathology

23. • Blood routine
• Relative lymphocytosis
• HB
• ESR

24. Smear and culture
• Aspiration or biopsy
• AFB staining
Culture
• LJ medium -6 weeks
• BACTEC
Radiometric method
Radioactive C14 tagged to fatty acid palmitic acid
MTB  radioactive 14CO2

25. Serological test
• Elisa for TB-6 antigen
PCR
• 100% specific
• Cant differentiate between live and dead bacteria
RT-PCR
• m RNA -----COMPLEMENTARY DNA
• Active bacilli detected

26. • REAL TIME PCR
• FASTER method
• Result 30-120 minutes

27. Bone scan
• Used in affluent countries
• Lacks specificity
• Tc99 Ga67 In111

28. • Biopsy
True cut
open biopsy
CT guided biopsy
• Guinea pig inoculation
• Detection in peritoneum after 8 weeks

29. TB HIP- classification
Sites
• Acetabular roof---most common
• Femoral head
• Neck of femur
• Babcocks triangle
• Trochanter
• Rarely synovium

32. STAGES
• I.TB SYNOVITIS
• Irritable hip
• Held in maximum joint capacity
• Flexion abduction external rotation
• Only extremes of movement are painful
• Xray/USG- soft tissue swelling +/- rarefaction of hip bones
• D/Ds- Traumatic synovitis, Rheumatoid/Transient synovitis, low
grade infections, perthes, SCFE

33. II EARLY ARTHRITIS
• Joint destruction advances
• Spasm of soft tissues around hip
• Deformity of
• flexion adduction internal rotation

35. • True shortening not more than 1cm
• Muscle wasting
• ROM painfull in all directions
• X ray-
o Reduced joint space,
o Articular margin erosion
o Localised osteoporosis

36. III ADVANCED ARTHRITIS
• Further joint destruction
• Deformities and clinical findings exaggerated
• Xray- gross destruction of articular cartilage and bones of
femur and acetabulum. Capsule is further thickened,
destroyed and contracted

38. IV ADVANCED ARTHRITIS WITH
SUBLUXATION OR DISLOCATION
• WIDE RANGE OF PRESENTATIONS
• With further destructive changes
• Proximal femur migrated upwards
• Wandering acetabulum
• Lower part of acetabulum becomes empty
• Shentons line broken on x ray

41. • Protrusio acetabuli
• Kohler's line (ilioischial) broken
• Pseudo acetabulum formation
• Coxa breva
 Reduced growth of head and neck and trochanter
 Rapid development of joint effusion  TAMPONADE EFFECT
• Coxa vara and Adduction deformity
• Destruction of femoral head and neck with normal greater trochanter

42. • Coxa valga
• Normal head and neck with restricted growth of trochanteric physis
• Coxa magna
• Growing age
• Hyperemia---isolated growth of head and neck
• Mortar and pestle appearance
• Severely deformed head and neck in a widened acetabulum

44. • Flexion external rotation and abduction
• Adopting painfree attitude
• Destruction of ilifemoral (ligament of Bigelow)

45. RADIOLOGICAL CLASSIFICATION
• Suggested by SHANMUGASUNDARAM
• ADULT
• Atrophic type
• Wandering acetabulum
• Protrusio acetabuli type
• Mortar and pestle type

46. • CHILDREN
• Normal type
• Perthoid type
• Dislocated hip type
• Protrusio acetabuli type
• Atrophic- Wandering acetabulum type
• Mortar and pestle type

48. MANAGEMENT
• Early diagnosis , effective chemotherapy – vital to save the joint
• Depends upon the stage of clinical presentation
• Rx includes : ATT
Absolute bed rest
Traction
Hip mobilisation exercises
Osteotomies
Excision Arthroplasty
Arthrodesis
THA

50. 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

51. • After 4-6 months of Rx – Ambulation with crutches / orthosis
• Ambulation :
• 1st 12 wks – non weight bearing: 2nd 12 wks – partial weight bearing
• Unprotected wt bearing – 18-24 months after onset of Rx
• Newer studies- wt bearing whenever tolerable

52. CATEGORY TYPE OF PATIENT REGIMENS DURATION
1. New Cases -New sputum smear +
-Seriously ill ,sputum –ve
-Seriously ill ,EP
-Sputum negative
-EP not seriously ill
2(HRZE)3 + 4(HR)3 6 MONTHS
2. Retreatment cases -sputum positive relapse
-sputum positive failure
-sputum positive treatment after
default
-2(HRZES)3+ 1(HRZE)3
-5(HRE)3
8 MONTHS
3. MDR TB Cases 6(9)K O Et C Z E /
18( O Et C E )
24 – 27 MONTHS

53. MDR TB
• MDR –TB: Bacteriological Dx
• If the infecting organism is resistant to
• INH
• Rifampicin with/without resistance to other ATT
• XDR-TB : MDR –TB strains resistant to FLUOROQUINOLONES
& one of the Injectables– Kanamycin, Amikacin,

54. Resistant /therapeutically
refractory case
• In clinical orthopedics –
• No response to ATT / No progressive healing
• Destructive process
• Continuing discharging sinuses, ulcers
• New cold abscess appearance
• Increasing size of existing cold abscess

55. Rx for Drug resistant TB
• Isolated INH resistance –Rx : Rifampicin
• Pyrazinamide
• Ethambutol –9M
• Isolated Rifampicin resistance – m/c in HIV pt
• Rx – several combinations for extended period (upto 18
months)
• Isolated Pyrazinamide resistance – Rx: INH, rifampicin for 9
months

56. Rx of MDR – TB
• Initial phase – 5 drugs – 6months
• Continuation phase – 4 drugs – 18 months
• 6 ( K O Et C Z E )/18 (O Et C E)
• K – kanamycin ,O – ofloxacin , Et -Ehionamide
• C – Clycloserine,Z – Pyrazinamide,
• E - Ethambutol

57. Rx of XDR – TB
• Higher generation FLUOROQUINOLONES are added to the
core regimen
• LEVOFLOXACIN –fluoroquinolone of choice
• Most forms of EPTB are adequately Rx with INH & Rifampicin
• 9-12 months course

58. Rx – Synovitis stage
• Chemotherapy – ATT
• Bed rest
• Traction
• Mobilisation exercises
• Prognosis – very good
• Surgical intervention – usually not required

59. Rx – Early Arthritis
• Chemotherapy– ATT
• Traction
• Analgesics supplementation
• Non wt bearing ROM exercises started as permitted, f/b
ambulation with orthoses
• Synovectomy & joint debridement with caution
• Vigorous passive exercise  pain, spasm. Thus avoided
• Prognosis in general – good– correctable deformities and
minimal shortening

60. 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
• Post sx- skeletal traction

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

62. • In advanced arthritis usual outcome- FIBROUS 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

65. 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

66. • 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
• Curettage of juxta articular infected tissue

67. Operative tech – IA arthrodesis
• Standard anterolateral/iliofemoral approach
• Grossly diseased capsule, synovium removed
• Joint dislocated carefully
• Excise cartilage, subchondral bone from femoral head &
acetabulum down to cancellous bone
• Repose the rawed head into freshened acetabular cavity, place
cancellous bone graft all around the joint

68. • Keep the joint in best functional position & insert 2-3 long
steinmann pins from base of GT – femoral neck & head –
going into acetabulum
• Apply hip spica
• After 6-8wks pins removed
• Gradual Wt bearing with POP on, is started using crutches
• Immobilisation & wt bearing continued for 4-6 months

69. • Very difficult to perform conventional arthrodesis if extensive
destruction / sequestration of femoral head & neck
• Rx – ABBOTT –LUCAS tech of fusion of hip in 2 stages

71. Abbott & Lucas arthrodesis
• Can be done in active infection
• ATT cover is mandatory
• 1ST STAGE : Anterior Smith –Peterson approach
• Remove capsule & debride joint
• Remove femur neck stump& denude GT
• Debride GT & acetabulum to bleeding cancellous bone, then
place GT into acetabulum with limb in wide abduction
• 30-90 deg abduction may be necessary, av -45deg

72. • 2nd STAGE: 4-8 wks later, osteotomy carried abt 5 cm below LT
through 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

73. Brittain’s tech of EA arthrodesis
• Expose proximal femur laterally, stay out of involved joint
capsule
• Perform subtrochanteric osteotomy angling upwards towards
ischium beneath the involved acetabulum
• With a currette, fashion a hole in the ischium below the
involved hip joint capsule & drive the tibial graft across
osteotomy site into ischium

75. • No internal fixation is used
• Hip spica applied
• After 8th wk post op – walking is undertaken in the cast for
upto 6months till fusion occurs

76. Disadvantages of arthrodesis
• Early development of degenerative osteo arthrosis in LS
spine,ipsilateral knee, contralateral hip
• Compensation for fused hip :
• Incr. Rotation of pelvis
• Incr. flexion of ipsilateral knee during stance phase

77. • Early development of degenerative osteo arthrosis in LS
spine,ipsilateral knee, contralateral hip
• Compensation for fused hip :
• Rotation of pelvis
• flexion of ipsilateral knee during stance phase

78. 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

83. • Some degree of SHORTENING, INSTABILITY
• Mean loss of length – 1.5 cm
• Shortening decr. by postop prolonged TRACTION in 30-50 deg
of abduction upto 3months
• MILCH - pelvic support osteotomy at the level of ischial
tuberosity ,also reduces instability

84. 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

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

87. 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

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

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

90. references
• Tuberculosis of skeletal system by S.M.Tuli
• TB hip- A current concept review- Indian Journal of
Orthopaedics 2014
• Saraf SK
• Tuli SM