tuberculosis of hip

1. Tuberculosis of Hip joint and
Management.

2. HISTORICAL ASPECT.
• Oldest recognised disease of mankind- “White plaque”.
•3500-1800 BC YAKSHMA-Ancient sanskrit word.
• Hippocrates -described-fever,colorless urine,cough resulting in a thick
sputum ,loss of thirst & appetite.

3. • Greeko-Roman civilization- “PHTHISIS” or Consumption.
• 1779-Percival Pott- Pott’s disease.
• Rene Laennec(1781-1826)-a French scientist, suffered
himself from tuberculosis and eventually died from the
disease.
• Robert koch discovered Mycobacterium tuberculosis in
1889.

4. EPIDEMILOGY.

5. • Global incidence-9.1 million ; Annual incidence-1.9million alone in
India.
• Prevalence- 3.8 million.
• Socio-Economic status.
• Risk factors- Poor sanitation , overcrowding , alcohol abuse etc.

6. CHARACTERTICS

7. TUBERCULOSIS OF HIP JOINT.
• Second most common joint.
• 15% - osteoarticular.(7 Hip:10 Spine)
• Seen first 3 decades of life.
• M>F.

8. PATHOGENESIS.
• Osteorticular TB- Secondary.
• Primary focus –Active or latent.
• Tubercle –Microscopic pathological lesion.
Caseating exudative type Proliferative type

11. COLD ABSCESS.
• Cold abscess Joint cavity.
• Inferior part of capsule Pelvis
Acetabular floor perforated. Leavator Ani
Swelling Above Below
Femoral triangle, Medial,
Lateral , posterior aspect of thigh Inguinal Ischiorectal fossa

13. CLINICAL FEATURES.
• Commonest age : 1st 3decades
• Pain –referred to knee-Night cries.
8%-Abscess +/- sinuses ; 10%-Pathological Subluxation/dislocation of
Hip.
• Limping –earliest-Antalgic gait.
• Active stage- Tenderness around the hip joint.
• Deformity- stage of disesase.
• Fullness around hip-Cold Abscess.

14. STAGES OF TB HIP
• STAGE OF SYNOVITIS:
Synovitis- Juxta articular lesion.
Irritable Hip.
FABER- Apparent lengthening.
Limited and painful movements.
X-ray- Soft tissue swelling +/- Rarefraction of the hip joint

15. • DD- Traumatic synovitis ,RA , Pyogenic infections , Perthe’s disease ,
SCFE.
• Repeat investigation – 3-6 weeks.
• IOC-USG- Swelling in soft tissue-Hip joint
• Biopsy- Bacteriological and histological investigations.

17. STAGE OF EARLY ARTHRITIS
• Destruction- Articular cartilage.
• Local signs of inflammation-Increased.
• Spasm- Adductors and Flexors.
FADIR – Apparent shortening .
• Muscle wasting.
• Restriction of movements.

18. X-ray.

19. STAGE OF ADVANCE ARTHRITIS.
• Gross destruction.
• FADIR- exaggerated –Apparent and
true shortening.
• Restriction of the movements.
• Muscle wasting.
• Capsule – Thickened and contracted

20. clinical

21. X-ray

22. STAGE OF ADVANCED ARTHRITIS WITH
SUBLUXATION OR DISLOCATION.
• Destruction-Acetabulum, femoral head, Capsule and ligaments.
• Shenton’s arc- broken.
• Posterior Dislocation of the hip.
• Protrusio Acetabuli.
• Restricted movements.
• Classical deformity-FADIR- NOT seen.

23. • Plastered >12 months – premature closure –growth plates- “FRAME
KNEE”.
• Growing age – Hyperemia & overgrowth femoral head and neck – “
COXA MAGNA”.
• Growing age – Destruction of the femoral head and neck, normal GT-
”COXA VARA”

24. Shanmugasundaram classified.
.
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)

26. X-RAY FINDINGS.
•Localised osteoporosis-”Washed out appearance”.
•Soft tissue swelling.
•Joint space narrowing.
•Subchondrol erosions.
• Deformity.

27. INVESTIGATIONS.
• CBC-Anaemia , lymphocytes increased.
• Raised ESR.
• Mountax test (children)
• TB ELISA- 60-80% sensitive- M.antigen-6-(1:32).
• Biopsy and HPE examination.
• C-reactive protein- prognostic factor.

28. • Synovial fluid analysis-leucocytosis,
Glucose – reduced,Protein-reduced,mucin clot-poor.
• USG- Soft tissue edema – TB tenovaginitis.
• CT-SCAN.
• MRI-effusion, periarticular osteoporosis, thickening of synovial memebrane.

29. Sputum examination-AFB

30. Aspiration of abscess.
• Smear & culture of pus.
SOLID MEDIA: 3-8WEEKS LIQUID MEDIA :1-
3WEEKS
LJ- Media
Middlebrook 7H11.

31. BACTEC media-Faster culture (1-2weeks)

32. AIM.
• Painless .
• Symptom free
• Stable
• Freely movable joint.
• Normal gait
• No deformity
• No shortening.

33. GENERAL
• GOOD DIET.
• FRESH AIR.
• SUNLIGHT.
• EDUCATION.

34. CHEMOTHERAPY.

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

38. Rx-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)

39. Rx-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

40. LOCAL TREATMNET.
STAGE OF SYNOVITIS AND EARLY ARTHRITIS.
• ATT
• Tractions.
• Cold abscess aspiration.
• Active assisted hip movements-Pain is subsided.
• Unfavourable response- Synovectomy or debridemnet.

41. ADVANCE ARTHRITIS.
• Fibrous ankylosis-outcome.
• Traction and exercises- deformities.
• Gross ankylosis-Plaster hip spica- 4-6months.
• 5-10deg external rotation; flexion deformity-30deg;Neutral
between abduction and adduction.
• Partial weight bearing mobilisation with crutches-after 6 months

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

44. • 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

45. Operativetech – IAarthrodesis
• 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

47. • 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

48. • Very difficult to perform conventional arthrodesis if extensive
destruction / sequestration of femoral head & neck.

49. Abbott & Lucasarthrodesis
• 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, avg -45deg

50. • 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 -5-10 deg of external rotation, flexion of hip in
30deg,abduction 5-10deg;which is removed after consolidation

51. Excisionarthroplasty
• 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

53. • 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.

54. Hip replacement inTB
• 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

56. • 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

57. THANK YOU.