tuberculosis of hip

1. TUBERCULOSIS
OF HIP
DR PARDEEP BANSAL
DR SULTHAN BASHA

2. Historical aspects
 ROBERT KOCH
discovered
Mycobacterium
tuberculosis in
1882

3. INTRODUCTION
 OLDEST DISEASE OF HUMAN BEINGS
 TB HIP – 2ND ONLY TO SPINE
 SPINE:HIP RATIO – 10:7
 OSTEOARTICULAR TB – 1-3% OF ALL TB CASES ,OF
WHICH TB HIP – 15-20%
 M>F
 AGE GROUP 20-30YRS

4. CAUSATIVE ORGANISM
 MYCOBACTERIUM TUBERCULOSIS M/C HUMAN
PATHOGEN
 SIZE – 3X.3UM
 GRAM POSITIVE AFB
 HEMATOGENOUS DISSEMINATION FROM PRIMARY FOCUS
 BONE AND JOINTS TB DEVELOP GENERALLY 2-3 YRS AFTER
PRIMARY FOCUS

5. Pathogenesis & Pathology
Primary focus
(Active/quiscent,Apparent/latent)
Hematogenous dissemination
2-3 yrs
Osteoarticular TB

6. 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.
 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 .

7.  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 )

8. Cold Abscess
 Collection of products of liquefaction & reactive exudation
 Contains - serum,
leukocytes,
caseous material,
bone debris,TB bacilli
 Feels warm ,but temperature not raised as high as in acute
pyogenic infection
 Bursts Sinus/ulcer formation

9.  Cold abscess forms within the joint – inferior weaker part of the
capsule
Perforated
Cold abscess presents anywhere around the hip – femoral triangle
Medial,lateral/ posterior aspect of thigh
Ishcio rectal fossa
Pelvis

10. Intra pelvic abscess
Below the levator ani Above levator ani
Ischiorectal fossa Upwards into
inguinal region

11. Common sites..
 Initial focus may start in
1. Acetabular roof –m/c
2. Epiphysis/Femur Head
3. Metaphyseal region
4. Greater trochanter-least
common

12. Types of Disease
CASEOUS EXUDATIVE
 More destruction
 More exudation
& abscess
formation
 Insidious onset
 Marked
constitutional
features
GRANULAR
 Less destruction
 Abscess
formation rare
 Insidious onset
& course
 DRY lesion

13. Fate of tubercle
 Resolve completely
 Heal completely with residual deformities/ loss of function
 Lesion completely walled off,caseous tissue – calcified
 Low grade chronic fibromatous, granulating & caseating lesion
may persist
 Infection spreads – contiguous,systemically

14. 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

15. Classification

16. STAGES OF T.B. HIP

17. Synovitis stage..
 Position of max joint capacity – FABER
 Apparent LENTHENING
 Only extremes of movement are painful
 DD – Traumatic synovitis
- Nonspecific Transient Synovitis
- Low grade pyogenic infection
- Perthes disease
- SCFE
 USG repeated at 2-3 wks
 X-Rays: soft tissue sweling,Rarefaction

18. Early Arthritis stage..
 Articular damage starts
 Severe muscle spasm- FADIR
 Apparent shortening
 Restriction of movements in all directions
 Appreciable muscle wasting
 MRI – synovial effusion
- minimal ares of bone destruction
- osseous oedema
 X-Rays: OSTEOPENIA, marginal bony erosions
NORMAL JOINT SPACE

19. Advanced Arthritis ..
 FADIR
 True shortening
 severity of symptoms
 Capsule further dstroyed ,thickened & contracted
 X-Rays : Destruction of articular surface
Joint space

21. Advanced arthritis with
Subluxation / Dislocation
 With further destruction of acetabulum, femur head
,capsule & ligaments the upper end of femur is
displaced upwards & dorsally in the wandering /
migrating acetabulum leaving its lower part empty &
broken – Pathological dislocation of femur head
 Movements are grossly restricted

22. CLASSIFICATION - RADIOLOGICAL
APPEARENCE
 Shanmugasundaram in 1983 classified the radiological appearences as
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)

23. Shanmugasundaram’s
Classification

25. PROTRUSIO TYPE ATROPHIC TYPE

26.  If the disease occurs during chilhood
1. Chronic hyperaemia Enlarged femoral head epi & metaphysis
COXA MAGNA
2. Thrombo embolic phenomenon of selective terminal vasculature
changes similar to PERTHES disease
3. a)Gross blood supply of femoral head due to TE
b) Rapidly developing tense IC effusion (Tamponade effect)
reduced femoral head & neck size
COXA BREVA

27.  Restricted growth of epiphyseal plate & normal trochanteric growth
plate COXA VARA
 Restricted trochanteric growth & normal femoral head COXA
VALGA

28.  Close relationship b/w radiological type & therapeutic
outcome:
1. Normal type - 92% good results
2. Perthes type - 80% good results
3. Dislocating type – 50% good results
4. Travelling acetabulum & Mortar pestle type - 29%
good results

29. Evaluation
 Hematological – ESR,relative lymphocytosis
 Bacteriological –AFB staining & C/S
 Serological – ELISA –serum IgG,IgM
 Histology – HPE for ‘ TUBERCLE ‘
 Molecular – PCR using 16sr RNA
 Clinico –radiological : X-Rays,
CT Scan
MRI
USG

30.  Synovial fluid aspiration
AFB positive in 10 – 20% of cases
Cultures positive in 50% of cases
 Aspiration of cold abscess for microbiology
 Synovial Biopsy
More reliable
Cultures positive in 80% cases
Histology : granulomatous inflammation

31. Bacteriological diagnosis..
 Specimen stained for AFB & C/S
 Stains used: - ZIEHL NEELSEN stain
- Auramine Orange fluorescence
 Media used for growth: Lowenstein- Jensen
 Conventional AFB C/S – 4wks
- requires live organism
- long incubation period
- low sensitivity in pts already on ATT
 Newer rapid culture tech- BACTEC

32. BACTEC : Radiometric culture system
- Detects Mycobac as early as 7-14 days
- Based on release of radiolabelled CO2 from the
growth of Mycobac in selective LIQUID media using
C14labelled sustrate

33.  Diagnosis – Clinico radiological in endemic areas
 Paucibacillary Disease – Bacteriological diagnosis is possible in 10-
30% cases only
 HPE & PCR –diagnostic
 Emerging MDR strains – threat to cure the TB lesion , thus TB bacilli
should be isolated & subjected to drug susceptibility

34. Serology..
 IgM – diagnostic of activity of the disease
 IgG – diagnostic of chronic disease/healed
disease
- levels remain high even after full Rx
 ELISA antibody values are dependent on
- time of taking sample
- state / phase of the disease
 Antibody titres donot correlate with recovery status of the patient.

35. Molecular diagnosis..
PCR – single test which amplifies the genome
even if a single organism was present
 Ideal for detection of paucibacillary TB case
 Many target genes of Mycobacteria
 16sr RNA – used as target sequence as it is universally
present false negative
- genus specific marker

36. Advantages of PCR..
1. Highly efficient & rapid method for Dx – 3days
2. Great value in early Dx
3. Very sensitive tech – could detect as few as 1-2 mycobac in the
specimen , and Rx initiated based on this result if clinical signs of
disease present
4. Can differentiate typical from atypical mycobac
5. Requires very small quantity of specimen – even microlitres of FN
aspirate can be tested

37. Disadvantages ..
 Notable to differentiate live from dead org, as it is not
dependent on bac replication
 Doesnot tell about the activity of the disease
 PCR positive results doesnot always confirm to culture
results
 PCR – not a substitute for culture

38.  Culture – gold standard
 CT guided FNAC – useful & minimally invasive method of
ascertaining HP Dx
 Screening tests :
1. Tuberculin skin test/Mantoux test
2. Interferon gamma release assay (IGRA)

39. Tuberculin skin test..
 Purified protein derivative (PPD) of tuberculin
(Antigenic culture extract) injected intradermally 0.1ml
into volar / dorsal aspect of forearm(0.1ml =
0.0002mg PPD)
 Results read after 48-72 hrs
 Positive : > 10mm induration
 Measures delated hypersensitivity

40.  Causes of false negative PPD test :
1. Age > 70 yrs
2. Steroid use( Prednisolone >15mg/day)
3. Hypoalbunemia(<2g/dl)
4. Azotemia
5. Impaired cellular immunity
6. HIV infection

41. IGRA..
 Measures the release of IFN – Υ by mononuclear cells
stimulated by specific M. Tuberculous antigens
 Useful test for latent TB
 Good sensitivity & specificity
 Particularly helpful in distinguishing TB from non
tuberculous Mycobac

42. Radiological ..
 X-Rays
 USG
 CT – Scan
 MRI

43. Management..
 Early diagnosis , effective chemotherapy – vital to save the joint
 Depends upon the stage of clinical presentation
 Rx includes : ATT
Absolute bed rest
Traction
Excision Arthroplasty
Arthrodesis
THA

44. 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

45.  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

46. 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

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

49. Resistant /therapeutically
refractory case :
 In clincal orthopedics –
1. No response to ATT / No progressive healing
2. Destructive process
3. Continuing discharging sinuses , ulcers
4. New cold abscess apearence
5. size of existing cold absces

50. 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

51. 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

52.  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 for
1. TB meningitis
2. POTT’S disease
3. Any EPTB that remains culture positive longer than expected

53. Rx – Synovitis stage
 Chemotherapy – ATT
 Bed rest
 Traction
 Mobilisation exercises
 prognosis – very good
 Surgical intervention – usually not required

54. Rx – Early Arthritis
 Chemotherapy – ATT
 Traction
 Analgesics supplementation
 Non wt bearing ROM exercises started as permitted
 Synovectomy & joint debridement
 Passive exercise pain,spasm . Thus avoided
 Prognosis in general - good

55. 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

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

57.  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

59. 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

60.  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
- Curretage of juxta articular infected tissue

61. Operative tech – IA
arthrodesis
 Standard anterolateral 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

62.  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

63.  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

64. 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

65.  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

66. 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

68.  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

69. Disadvantages of arthrodesis
 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

70.  Activities max limited after fusion
- bending,sitting on floor, cross legged sitting ,
- Squatting,kneeling,bicycling
 Thus no pt would accept a fused joint

71. Excision arthroplasty..
GIRDLESTONE – described excision of femoral
head,neck,proximal part of trochanter & acetabular rim for chronic
dep 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

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

75. 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

76.  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

77. 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

78. Rx in children..
 In children with arthritis –Traction
failure
Open arthrotomy
Synovectomy
Debridement of diseased joint
 Arthrodesis deferred till growth completion

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

80. THANK YOU