3. INTRODUCTION
Next to spine, hip joint is the most common site for
involvement by tuberculosis.
Mostly common first 3 decade of life like other osteo –
articular disease.
It constitute 15 percent of osteoarticular tuberculosis.
4. 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.
5. 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
Cold abcess in joint – perforate inferior weaker part of capsule
rarely acetabular roof – cold abcess can present anywhere around
the hip ( femoral triangle , medial ,post and lateral side of thigh
,ischeo – rectal fossa , pelvis )
6. CLINICAL FEATURES
Insidious in onset
Pain and swelling in the hip and limping are the usual presenting
symptoms
Sometimes there is referred pain in the knee and is often misleading.
Pain is maximum at end of day. Child may wake up from sleep due to
pain(night cry)
Constitutional symptom like loss of appetite, loss of weight, fever
Limp is the earliest and commonest symptom
7. During changing of bed patient may support the involved
limb with contralateral normal limb. Or pt can “apply
traction” on the painful hip on the dorsum of foot by
contralateral limb
8 % patient may have palpable cold abscess with or
without sinuses .
10% present with pathological subluxation or dislocation
Typical antalgic gait
8. STAGES OF T.B. HIP
Stage 1: Synovitis
Stage 2: Early Arthritis
Stage 3: Advanced Arthritis
Stage 4: Advanced Arthritis with Sequele
9. STAGE 1: Synovitis
Synovitis with effusion into the cavity.
The hip joint assumes the position of maximum capacity –FABER --flexion,
abduction and external rotation causing apparent lengthening
Pelvic tilt downwards which cause apparent lengthening of affected limb
Increased lumbar lordosis
Other local signs are warmth, tenderness, muscle spasm and painful
limitation of all movements of the joint
D/D – traumatic synovitis , rheumatic , non specific transient synovitis ,
perthes ds , low grade pyogenic infection
10. STAGE 2: Early Arthritis
If disease is untreated and the patient is bed-ridden destructive process
spreads to the articular surface
Limb assumes the position of flexion, adduction (apparent shortening) and
internal rotation (FADIR)due to spasm of adductors
True shortening not more then 1 cm because ht. of articular cartilage is one
cm
There is marked muscle wasting of gluteal muscle
Cold abscess formation occurs
X – ray: localized osteoporosis , decrease in joint space due to decrease in ht
of articular cartilage, localized erosion of articular cartilage .
11. STAGE 3: Advanced Arthritis
Clinical sign of stage 2 is exaggerated
Gross destruction of articular cartilage and
femoral head and acetabulum
12.
13. STAGE 4: Advanced arthritis with
subluxation or dislocation
With further destruction of capsule and ligaments head of the
femur and may shift upwards and dorsally
Wandering or migrating acetabulum
Dislocation or subluxation may occur
Protrusion acetabuli occur
Mortar and pestle appearance ( collapse and small femoral head
and neck lie in enlarged acetabulum )
Adduction, flexion and internal rotation gets exaggerated
There is real shortening of limb
Cold abscess bursts and there are sinuses discharging thin pus
14. Hip may not assume the posture of triple deformity of
F- AD – IR instead hip may assume F – AB – ER . This
may be due to continuous adoption of lateral aspect
of thigh of diseased hip resting on bed or due to
destruction of iliofemoral ligament
If limb has been plastered more than 12 month as in
first half of twentieth century growth plate around the
knee may get closed – frame knee
Coxa magna , coxa valgus , coxa vara
15. RADIOLOGICAL FEATURES
STAGE 1- generalised rarefaction of bones. Joint space
appear widened due to effusion
STAGE 2- erosion of the articular surface and narrowing
of the joint space
STAGE 3- destruction of head of femur, dislocation of hip
and a break in the shenton’s line
16. Radiological type of tuberculosis
(acc. to Shanmugasundram)
Type 1 – normal
Type 2 – migrating acetabulum
Type 3 - pathological dislocation
Type 4 – perthes disease
Type 5 – protrusion acetabula
TYPE 6 – atrophic type
Type 7 – mortar and pestle appearance
17.
18.
19.
20.
21.
22.
23. Hyperemia – large head and neck – coxa magna
Thromboembolic phenomena – perthe’s disease
Coxa breva due to decrease in blood supply
Restriction growth of capital femoral epiphyseal plate and
normal trochanteric physis – coxa vara
Normal growth of capital femoral epiphyseal plate and
Restriction
trochanteric physis – coxa valga
If joint space is reduced > 3mm – poor prognosis
26. Aim of management
Painless
Stable
Mobile
No deformity
No limp
No limb length discrepency
27. Synovitis and early arthritis
Traction is given to correct deformity and to give rest
to the part. Traction relieves muscle spasm and
maintains joint space.
Any palpable cold abscess should be aspirated with
instillation of streptomycin.
Active assisted movement should be started as soon as
pain subsides
After 4-6 months ambulation on suitable caliper or
crutches
In presence of abduction deformity , for better control
of pelvis b/l traction is mandatory otherwise abduction
deformity will increase
28. Advanced arthritis
The usual outcome is gross fibrous ankylosis.
Initial traction regime help to overcome deformity and
returns any useful range of motion.
Once gross ankylosis is anticipated the limb should be
immobilized in hip spica.
The ideal position is neutral between abduction and
adduction,5-10 degree external rotation,and flexion
between 10degree in children to 30 degree in adults
29. Role of surgey
Synovectomy
Debridement
Arthrodesis
Arthroplasty
30. Arthrodesis
unsound ankylosis with healed or active disease
deferred till the bone of hip has growth potential
extra articular arthrodesis – ischiofemoral or iliofemoral
arthrodesis
intra articular arthrodesis –with modern anti tubercular drugs
, between raw surface of femoral head and acetabulam
31. Excision arthroplasty
Girdelstone’s excision arthroplasty –
can be done in active and healed stage
after the completion of growth potential
Provide painless , mobile joint and control of infection and
correction of deformity
However there is shortening of 3.5 – 5 cm and instability
which can be reduced by post op traction( 3 mnths ) .
With long term follow up improvement in bone texture and
remodelling and false joint formation .
32. Joint replacement
After maintaining 5 yrs. of healed status
After replacement 5 months anti tubercular drugs
Still reactivation occurs in 1/3 patients
33. PROGNOSIS
Early anti TB drugs – good prognosis
Early disease ( synovitis and early arthritis ) –
good prognosis
Advanced arthritis – fibrous ankylosis
TB may interfere blood supply of head – same as
perthese disease – should be treated like perthes
disease with antituberculer coverage