TB hip ug presentation

1. TUBERCULOSIS OF
HIP
BY – DR. SANTOSH M S
ASSISTANT PROFESSOR
DEPT. OF ORTHOPAEDICS

2. History

3. Morphology
 Bacteria – Mycobacterium Tuberculosis
 Aerobic
 facultative intra-cellular organism
 Non-spore forming , non-motile
 Rod shaped : 2-5mm long
 Once stained it resists
decolorization with acid/alchohol.
 It has mycolic acid in cell wall – Acid fast bacilli
 Human being the main resorviour

4. Pathology of TB
 Entry of infection into body
 Accumulation of macrophages
 TB bacilli phagocytosed – lipid from cell wall dispersed int
cytoplasm
 Epitheloid cells – large cells with abundant cytoplassm
 Group of epitheloid cells – form Langhans gaint cell.
 Tubercle – Lymphocytes surround gaint cells in periphery
which appear as nodule in reticulo-endothelial cells.
 Tubercle – 2 types : Hard , Soft
 Soft type associated with caseous necrosis. Its presence is
diagnostic of Tb pathology. `

6. At risk groups
 Immunocompromised
 Diabetics
 Anticancer chemotherapy
 Immunosuppressive medication
 Chronic alchoholics
 Long term steroid therapy
 Malnourished children

7. Areas of infective foci
 In descending order –
1. Spine
2. Hip Least common areas :
3. Knee 1. Mandible
4. Foot 2. TM joint
5. Elbow
6. Hand
7. Shoulder
8. Bursal sheaths

8. Cold abcess
 Collection of – serum, WBC , Caseous material, bone debri,
TB bacilli
 It feels warm on palpation, though not as significant as septic
infection.
 If it bursts – form ulcer/sinus.
 It can form in the joint – usually weaker aspect of capsule
area
 Around hip – Femoral triangle, Medial / lateral aspect of
thigh.

9. Stages of osseous TB
1. Inflammatory edema & exudate
2. Necrosis & cavitation
3. Destruction & deformation
4. Healing & repair.

10. TB HIP
 Sites of infective foci
1. Acetabulum – MC
2. Femoral head/epiphyses
3. Femoral neck/metaphysis
(Babcock’s triangle)
4. Greater trochantrer

11.  TB of GT may involve overlying trochantric bursa
without involving hip joint for long time.
 Foci in upper end of femur – intracapsular – joint
involved rapidly.
 Foci in acetabular roof – joint involvement is late and
mild symptoms.
 Cold abcess forms in joint perforates the inferior
weaker part of capsule and presents any where
around joint.

13. Features specific to hip
 MC age group – first 3 decades
 Pain
 Limping – Earliest & MC
 Fullness over joint & painful/decreased
ROM.
 Deformity.
 Night cries
 Discharging sinus

14. Stages of TB Hip
 5 stages –
1. Tubercular synovitis
2. Early arthritis
3. Advanced arthritis
4. Advanced arthritis with subluxation/dislocation.
5. Terminal or Aftermath of arthritis.

15. 1. Tubercular synovitis
 Irritable hip
 Joint is held in position of maximum capacity –
F-AB-ER
 Apparent lengthening present with no true shortening.
 Terminal movements at hip painful, restricted.
 X ray- soft tissue swelling, haziness of articular margin
 USG- Soft tissue sweling.
 MRI- Synovial effusion.
 Biopsy – can be done to confirm by HPE &
Microbiological methods.

17. Differential diagnosis
1. Transient synovitis
2. Septic arthritis
3. Perthe’s disease
4. SCFE
5. Ilio-psoas abcess
6. Osteomylitis of femur head.

18. 2.Early arthritis
 Destruction of articular cartilages sets in
 Spasm of adductors & flexors occurs which gives
deformity picture – F-AD-IR.
 Apparent shortening & true shortening usually not
>1cm
 Global restriction ROM.
 X ray- Localised osteoporosis, decrease in joint
space, erosion of articular cartilage.
 MRI- Synovial effusion, minimal areas of bone
desrtuction with bone edema.

20. 3.Advanced arthritis
 Further destruction of joint
 True & Apparent shortening exaggerated
 Pt tends to sleep on normal hip further
contributes to deformity.
 X ray- Destruction of femur head and
acetabulum.
 Capsule also destroyed to a greater extent- thick
& contracted.

22. 4. Advanced arthritis with
dislocation/subluxation
 Further destruction of acetabulum, femur head,
capsule, ligaments occurs.
 Upper end of femur may displace upwards and
dorsally.
 Wandering/travelling acetabulum.
 Sometimes lead to posterior dislocation of femoral
head.
 Hip may show – Protrusio acetabuli
Mortar & pestle appearnace.

23. 5. Terminal or aftermath of
arthritis
 It is ankylosis of joint.
 Articular margins are adapted to the deformed
position
 Degenerative arthritic changes will be present.
 Grossly , joint may appear irregular , cobbled ,
deformed , pock-marked and devoid of articular
cartilage.

25. Phemister triad
 Periarticular osteoporosis
 Peripherally located osseous erosion
 Gradual diminition of joint space.

26. Investigations
1.Hematological –
- Anemia
- Lymphocytosis
- Raised ESR (often seen in active phase)
- Its repeated estimation at 3-6months
interval gives index of activity of disease.

27. 2. Mantoux test -

28. 3. Biopsy –
- More reliable procedure specially to prove
disease in early stages.
- Can be synovium, lymph node, bone
tissue.
- HPE – granulomatous inflammation with
epitheloid cells and gaint cells.

29. 4. Synovial fluid analysis –
- Lymphocytosis
- Glucose levels reduced
- Protein levels increased
- Excellent source for PCR
technique.

30. 5.Bacteriological investigations –
- Specimen sample stained for AFB, C/s
- Media used for growth – Lowenstein-
Jensen
- BACTEC –
 Detects microbe in 7-14 days.

31. 6)Molecular -
 PCR –
- highly specific for TB bacilli , amplifies
even if single organsim is present.
- Diagnosis can be made in 3 days.

32. Radiological
1. X ray –
- AP & Lateral view of hip with CXR to be done.
- 1st sign : localised osteoporosis (in active disease).
- Articular margins & bony cortex become hazy and
gradually destructive changes occur.
- Soft tissue swelling – due to synovial fluid, thickened
synovium, capsule & peri-articular disease
involvement.
- Joint space reduced – articular cartilage involved.

33. X ray findings in Left Hip

34.  Sequestrum –
- Centre of tuberculous cavity , sequestration of cancellous bone
or calcification of caseous tissue gives an appearance of
irregular, soft, feathery, coke like sequestrum.
- Sometimes sequestration
in cancellous bone is
due to ischemic infracts.

35. 2. CT scans –
- Helpful in demonstrating small destroyed
areas (lytic cavities) in bone and marginal
erosion.
- Soft tissue edema, granulations, exudation,
abcess formation can be diagnosed earlier
stage.
3. MRI scan –
- It shows pre destructive leisons like edema,
inflammation of bone in active disease

36. Management
 Two pathways –
1. Medical management
2. Surgical management.

37. Medical management
1. General
2. Anti-tb chemotherapy.
3. Rest
4. Traction ,if deformity present.
5. Mobilisation.

38. Anti TB drugs

39. Scheduled Anti TB drug treatment

40. 3.Rest
 All pt. are adviced to sleep on
hard bed.
 In active stages ,joint is
given rest in “position of ease”.
 Pt. in early stages are
adviced intermittent active & passive exercises to improve
funtional arc of joint involved.

41. 4.Traction
 It is one of the best modality to-
1. Correct deformity.
2. Maintain limb in functional position throughout treatment
3. Maintains joint space.
4. Relieves muscle spasm.
5. B/l traction to be put to stabilise the pelvis.
6. Prevent complications – dislocation/subluxation, widening of
acetabulum.

42.  Maintainace of traction and intermittent active and passive
motion of joint within range of tolerable pain during healing
process will –
1. Encourage development of healthy synovial membrane and
well lubricated fibrocartilage for joint function.
2. Induction of proliferating mesenchymal cells will metaplaise
the synovial cells.
 These process may permit good functional recovery of joint
even in joint damaged by tb lasting in healed status of
disease.

43. 5.Mobilisation
 After starting the treatment in initial stages –
 1st 12 weeks : Non-weight bearing
 Next 12 weeks : Partial weight bearing
Ambulation with orthosis/crutches.
 18-24 months : Unprotected weight bearing can
be started.

44. If advanced arthritis ?
 The usual outcome is gross fibrous ankylosis.
 The limb should be immobilised with help of hip spica for
about 4-6 months.
 Ideal position of immobilsation –
1. Neutral between adduction & abduction.
2. External rotation of 5-10 degree
3. Flexion – In children – upto 10 degree
In adults – upto 30 degree.
 After 6 months – partial weight bearing with hip spica
 After 2 yrs – with orthrosis & crutches.

45. Surgical management
 It is used as adjunct to chemotherapy but not substitute.
 Indications :
1. Clinically non-responsive disease
2. Failure to obtain acceptable outcome / deformity after
chemotherapy.
3. To obtain tissue for diagnosis.
- Before taking up for surgery , make sure pt. recieves
chemotherapy for 4weeks and physically fit for surgery.

46. Types of surgery
1.Synovectomy
2.Joint debridement
3.Osteotomy
4.Arthrodesis : Intra-articular
Extra-articular
Combined
5.Excision arthroplasty
6.Tectoplasty
7.THR

47. Management in children
 In children with arthritis , deformity , subluxation / dislocation is
corrected or minimised by Traction.
 Rarely , children go for operative procedure.
 Failure of correction / minimise the deforming changes will
require –
1. Open arthrotomy
2. Joint debridement & synovectomy.
3. Improvement of displacement.
 After completion of growth plate potential, can be taken up for -
1. Arthrodesis
2. Excisional arthroplasty

48.  Children presenting with healed gross deformity requires
extra-articular corrective osteotomy to enable them to
walk better until skeletal maturity.
 If there is no gross deformity of hip joint –
1. Sub-total excision of contracted fibrous capsule is done.
2. Traction and repititive exercises.
 This may be helpful in restoring a useful range of
movements for few years.

49.  Incidence of reactivation will be least –
1. Healed status achieved with remineralisation and
restoration of destroyed bone.
2. Healing of articular surface with near complete funtion
or bony ankylosis of destroyed joint or painless
fibrous ankylosis.
 Prognosis of disease -
1. With evolution of chemotherapy , tretament protocols
of TB has been changed.
2. If diagnosed early and treated with strict adherence to
chemotherapy, healing can be expected with good
mobility of joint.

50. THANK YOU