Tuberculosis of the Hip joint! Introduction Etiopathogenesis Classification Diagnosis Management

1. TUBERCULOSIS OF
HIP
Dr. Arpit V Joshi
NHL Municipal Medical College, Ahmedabad

2. Introduction
Tuberculosis is one of the oldest disease known to affect humans
Chronic granulomatous disease caused by Mycobacterium tuberculosis, others are
M.bovis & M.africanum
Extrapulmonary TB (EPTB) is 10-15% of all types of TB in India
Lymphnode TB is commonest of it.
While osteoarticular TB is 1-3% of it.
out of which most common is Spinal TB (50%) & TB hip is 2nd most common (15%)
Other joints are knee, elbow, foot & hand joints, shoulder (rare).

3. Risk Factors
Persons who have been recently infected with TB bacteria:
Close contacts of person with TB
Health care workers
i.v. drug users & persons with HIV infection
Persons with medical conditions that weaken the immune system:
HIV infection
DM
CKD
Malnutrition
Immunosuppresants
Alcohol& smoking

4. Pathology
All tissue changes in tuberculosis are due to cell mediated (type IV) hypersensitivity
reaction of host to several lipids of micro organism
TB bacilli are phagocytosed by macrophages
Epitheloid calls formation
Langhans giant calls formed by fusion of epitheloid cells
Lipids are dispersed in
cytoplasm of macrophages
This modified macrophages
resembles epithelial cells
Lymphocytes forms a ring around lesion Tubercle

5. Pathogenesis
Primary Focus
Haematogenous spread
(2-3 years)
Osteo-articular TB
Caseous Exudative type:
 More in Children
 More destruction
 More exudation
 Abscess & sinus formation
common
 Constitutional symptoms & signs
of inflammation are marked
Granular type:
 More in adults
 Less destructive
 Insidious onset &
course
 Abscess is rare
(‘Dry lesion’)

6. Sites of TB Hip
1) Acetabular roof (commonest) – late
joint involvement but presents with
extensive destruction
2) Femoral epiphysis – intracapsular, rapid
joint involvement
3) Neck/metaphysis/Babcock’s triangle
4) Greater trochanter (may involve
trochanteric bursae) – without
involving hip for long time
5) Rarely synovial membrane

8. Cold abscess
Collection of products of liquefaction and reactive exudation
Composed of serum, leucocytes, caseous material, bone debris, tubercle bacilli
Feels warm but not temperature not raised as pyogenic abscess
If bursts– Sinus/ulcer formation
If formed in ajoint, may present in femoral triangle, ischiorectal fossa, pelvis,
medial/lateral/post. asp of thigh

9. Intra pelvic abscess spread

10. Tubercular sequestra
Following infection, marked hyperemia & severe osteoporosis takes place
Osseous destruction by lysis of bone which is softened & yields under effect of gravity
& muscle action leading to
compression, collapse & deformation of bones.
Necrosis tales place due to ischemic infarction of bone segment
Infection plus infarction thus forms bone sequestrum.

11. Future course of disease
May resolve completely
Heal with residual deformities or loss of function
Lesion may be walled off completely and caseous tissue may be calcified
Low grade chronic fibromatous, granulating & caseating lesion may persist
Infection can spread- contiguous, systemically

12. Clinical Features
Commonly occurs in first 3 decades
Limp is earliest and commonest symptom
Pain may be absent in early stages, referred to medial asp of knee
Night cries
Constitutional symptoms: fever, loss of appetite, loss of weight

13. Physical signs
General:
 Pallor
 Lymphadinitis
 Signs of pulmonary TB
Gait:
 Antalgic/Trendelenburg
Inspection:
 Swelling around hip (cold abscess)
 Deformity of limb according to stage of disease
 Wasting of thigh muscles & glutei

14. Palpation:
 Joint line tenderness
 Muscle spasm- lower abdomen & adductors of thigh
 Shift of GT
Movements:
 Painful ROM
 Fixed deformities
Measurements: Apparent lengthening/shortening, true shortening(acc. to stages
of disease
Due to fixed deformities, secondary changes in spine (lordosis/scoliosis)

15. Stages of TB Hip
Stage I: Synovitis
 Juxtaarticular osseous lesion causing ‘irritable hip’
 Effusion in hip joint leading to hip in a position of maximum capacity, i.e. Flexion,
ABduction, External Rotation
 Stage of ‘apparent lengthening’
 Xray- soft tissue swelling, with/without rarefaction articular margins
 USG/MRI- effusion in hip joint

16. Stage II: Early Arthritis
 Articular cartilage involved
 Spasm of muscles around hip (flexors & adductors), leading to
 Hip in Flexion, ADduction, Internal Rotation
 ‘Apparent Shortening’
 Xray- Rarefaction, osteopenia, bony erosions in femoral head, acetabulum or both,
diminution in joint space, reduced vertical height of articular cartilage
 MRI- synovial effusion, minimal bone destruction

17. Stage III: Advanced Arthritis
 Destruction of articular cartilage & subchondral bone
 Capsule destroyed, thickened & contracted
 Flexion, ADDuction & internal rotation deformity
 True & apparent shortening
 Xray- early arthritis, destruction of articular surface, reduction in joint space

18. Stage IV: Advanced Arthritis with Subluxation/Dislocation
 Further destruction of acetabulum, femoral head, capsule, ligaments
 FADIR deformity with ‘Gross Shortening’
 Xray- grossly reduced joint space, wandering acetabulum, broken Shenton’s arc
 May show ‘protrusio acetabuli’
 Or, ‘Mortar & pestle appearance’, due to collapsed neck (coxa breva)
 Sometimes destruction of capsule and acetabulum so severe to lead to frank
pathological posterior dislocation

21. In general, the movements at this stage are grossly restricted
But in some cases with wandering acetabulum, protrusion acetabuli or Mortar &
pestle picture may retain fairly good range of movements for a long time
In certain cases of TB arthritis (stage II, III, IV), the hip may not assume the classical
triple deformity of F-AB-ER instead the deformity may be that of FF-AD-IR due to
destruction of iliofemoral Y ligament!
If limb plastered for longer duration, growth plate around knee may get closed- Flame
Knee

22. Radiological types of TB Hip
(Shanmugasundram)

24. ‘Phemister Triad’: Periarticular osteoporosis + peripherally located osseous erosion +
gradual diminution of joint space
Coxa Magna: TB hip in childhood causes chronic hyperemia, leading to enlargement of
femoral head epiphysis & metaphysis
Coxa Breva: Thromboembolic phenomena of terminal vasculature creates Perthe’s like
changes & reduced blood supply due to effusion (remponade effect) decreases size of
head & neck
Coxa Vara: restricted growth of femoral capital epiphysis with normal growth of
trpchanteric growth plate
Coxa Valga: restricted growth of trochanteric growth plate with normal growth of
femoral epiphysis

25. Investigations
Haematological: CBC/ESR/CRP
Bacteriological: ZN stein, BACTEC
Serology: IgM (active disease) IgG (chronic/healed disease)
Molecular diagnosis: PCR- very sensitive thus ideal for paucibacillary TB, highly
efficient, rapid(3 days), differentiate typical from atypical myco but can’t diff live
from dead organism, not confirmative
Synovial fluid: AFB positive in 10-20% cases, culture positive inn 50%
Synovial biopsy: cultures positive in 80%
Radiology: Xray, USG, CT, MRI
Screening test: Montoux & IFN gamma- can diff typical from atypical

26. Management
Aim: obtain painless, symptom free & stable but freely mobile joint with normal gait
without limp, deformity or shortening
Treatment: Chemotherapy

33. Local Treatment
Stages of Synovitis & Early Arthritis:
ATT
Traction
Aspirate cold abscess with instillation of streptomycin &/or INH
Active assisted hip movement once pain subside
Hip mobilization within limits of tolerable pain
Pt is allowed to sit, touch forehead, squatting
Ambulation with Caliper/crutches after 4-6 months
Non weight bearing 12 weeks
Partial wt bearing next 12 weeks
Unprotected wt bearing- 18-24 months later

34. Advanced Arthritis:
Usual outcome is fibrous ankylosis
If ankylosis is anticipated, limb is immobilized in plaster hip spica for 6-9 months in
neutral position in coronal plane, 5-10 degrees of ER & flexion acc to age (1 deg each
year upto 20 deg) 10 deg in children & 30 deg in adults
After 6 months, partial wt bearing with crutches/caliper for 2 years

35. Role of Surgery
Diagnostic- tissue culture
Therapeutic- joint debridement & clearance
Excision arthroplasty or arthrodesis
Rarely THR

36. Management in Children
Deformity & subluxation/dislocation- corrected with traction or spica with/without
tenotomy (adductor) under GA
Failure to do so, warrants open arthrotomy, synovectomy & debridement
Arthrodesis/excisional arthroplasty avoided till completion of growth potential; if
required extraarticular osteotomy performed to make them walk till maturity

37. Synovectomy & Joint Debridement
Performed without dislocating femoral head
Hypertrophied synovium separated
Thickened capsule excised
Diseased synovium from retinacular reflexions on head is curreted
Destroyed areas of head, neck, acetabulum is removed in debridement!!!
Complications: AVN, SCFE in children, # neck & acetabulum

38. Osteotomy
Sound ankyloses in bad position- upper femoral corrective osteotomy
Extraarticular procedure
Done at any age
Stay as close as possible to deformed joint

40. Arthrodesis
Deferred till the growth potential of prox. Femur completed
Indicated when, Failure of conservative Rx & Relapse of pain and deformity after
conservative Rx
Best Position: Neutral in coronal plane
5-10 deg. of ER
10-30 deg. Flexion

41. Intraarticular Arthrodesis
Performed in active disease
It allows, to obtain tissue for HPE
Joint exploration
Excision of tissue
Curettage of infected articular cavities
Supplementation of bone grafts
Anterolateral approach
Excise diseased tissues from head acetabulum & juxta articular cavities
Cancellous bone graft placed in large cavities and around joint line
Fix with 2 or 3 Steinmen’s pins, give hip spica for 6-8 weeks, remove pins after that, wt
bearing with spica & with crutched for 4-6 months until radiological fusion
Further protection with crutches for 1 year after spice removed

42. Abbott-Lucas’ technique of fusion of hip
joint
2 stage surgery
Indication:
Deficient stock due to prior arthroplasty
Extensive destruction of head & neck of femur
Pt lifestyle prefers strong, fused, painless hip
Can be done in active infection
Anterior Smith-Peterson approach
Remove capsule
Remove neck stump & denude GT
Debride GT & acetabulum until bleeding cancellous bone
Put GT into acetabulum, close wound, keep limb in 30-90 deg. Abduction

43. After 4-8 weeks, osteotomy 5 cm below LT through lower end of previous incision
Distal fragment displaced slightly medially to allow a part of prox fragment to fit into
medullary canal of distal fragment
Hip spica- removed after sign of fusion

44. Extraarticular Arthrodesis
Brittain’s technique/Ischio-femoral Arthrodesis

45. Disadvantages:
Early degenerative arthritis of LS spine, ipsilateral knee and contralateral hip
Limited activities
Compensation for fused hip: rotated pelvis & increased flexion of ipsilateral knee
while stance phase

46. Excision Arthroplasty
GIRDLESTONE:
Performed in active/healed disease.
Gives mobile, painless hip with correction of deformity & infection control
Anterior/anterolateral incision
Excise femoral head & neck in line parallel to intertrochanteric line
If joint ankylosed & can’t be dislocated, head & neck removed and 2-4 cm gap should be kept
between trochanter & pelvis
No projecting bone, raw surface cauterized, no soft tissue to be interposed, close wound with
drain

47. Post-op:
Proximal tibial ST pin traction in 30-50 deg. Abduction for 3 months
Active assisted hip & knee started during 1st week
Encourage to squat & in Tailor’s position
Mobilize with crutches/caliper- after 3 months
Walking with stick on contralateral side- after 6-9 months
Average length of shortening- 1.5 cm, prevented by traction upto 3 months
If instability, ‘tectoplasty’

49. Supra-acetabular shelf: full thickness iliac crest used to provide shelf at upper margin
of acetabulum
Pelvis support osteotomy: Milch-Bacheolar type at level of ischeal tuberosity

50. Hip replacement in TB
THA can be performed 3 years or more after last evidence of active infection
With combination of ATT for at least 2 weeks preop & 12 months postop