Osteoarticular Tuberculosis is still common in India,with Hip joint being the 2nd commonly involved site

1. TUBERCULOSIS of HIP JOINT
Dr.T.Anil kumar
2nd Year Postgraduate
Department of Orthopaedics
siddssidd
Siddhartha Medical College
Vijayawada,AndhraPradesh

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

3. Introduction
• 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%
• Primary focus
• THR in active stage of disease –another area
of controversy

4. Organism
• Mycobacteria belong to the
family- MYCOBACTERIACEAE
Order – ACTINOMYCETALES
• M.tuberculosis complex-
- M.tuberculosis – m/c human pathogen
- M.bovis-bovine tubercle bacillus
- resistant to Pyrazinamide
- transmitted by unpasteurised milk
-M.caprae,africanum,microti,pinnipedii,canetti

5. Organism .. • M.tuberculosis -
rodshaped,gram positive
nonsporeforming,
thinAEROBICbacilli
0.5µm × 3µm
• Once stained ,the bacilli
cannot be decolorised by
acid alcohol- thus called
ACID FAST BACILLI
• Acid fastness is due to high
content of MYCOLIC
ACIDS,long chain cross
linked fatty acids,other
cellwall lipids

6. Organism - Structure
• In the cellwall,lipids(mycolic acids) are linked
to underlying ARABINOGALACTAN &
peptidoglycans
Low permeability of cell wall
Reduced effectiveness of most antibiotics
• Genome comprises 4043 genes encoding
3993 proteins,50 genes encoding RNA’s

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

9. • Organism reaches joint space through either
1. Subsynovial vessels
2. Lesions in the epiphyseal bones
 Articular cartilage destruction begins
peripherally
 TB Arthritis- doesnot form proteolytic
enzymes in joint space central areas of
articular cartilage preserved for long time

10. 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. • TB of GT may involve the overlying
trochanteric bursa witout involving the hip
joint for a very long time
• Upper end of femur – intracapsular – joint
involved rapidly
• When initial focus starts in acetabular roof-
joint involvement is late ,symptoms mild

13. Tubercle/Granuloma formation...
• Initial stages of infection- usually
asymptomatic
• 2-4wks after infection- 2 host responses
1.Macrophage activated CMI: T-cell mediated
response Activation of macrophages
Killing & digesting tubercle bacilli
2.Tissue damaging response DTH to
various bacillary antigens
- Destroys unactivated macrophages that
contain multiplying bacilli

14. Insemination of infection
Accumulation of macrophages/monocytes
TB bacilli – phagocytosed,broken down
Lipid dispersed throughout the cytoplasm
EPITHELOID cells – large pale cells
large vesicular nuclues
Abundant cytoplasm
LANGHANS GAINT cells

16. Mass formed by reactive cells - Nodule/TUBERCLE
2wks
central CASEOUS NECROSIS
• Presence of caseous necrosis – SOFT TUBERCLE
• No caseous necrosis – HARD TUBERCLE Rx,
Atypical organism

18. 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

19. • 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

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

21. 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

22. 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

23. Clinical features..
• Commonest age : 1st 3 decades
• Limping – earliest,commonest symptom
- Antalgic gait
• Pain – reffered to medial aspect of knee
- max towards end of the day
• Deformity
• Fullness around the hip
• Night cries sleep awakening

24. Classification

25. 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

26. 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

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

29. 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

30. 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)

31. Shanmugasundaram’s Classification

33. PROTRUSIO TYPE ATROPHIC TYPE

34. • 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

35. • Restricted growth of epiphyseal plate & normal
trochanteric growth plate COXA VARA
• Restricted trochanteric growth & normal
femoral head COXA VALGA

36. • 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

37. 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

38. • 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

39. Hip joint aspiration..

40. 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

41. • 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

42. • 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

43. 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.

44. 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

45. 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

46. 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

47. • 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)

48. 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

49. • 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

50. 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

51. Radiological ..
• X-Rays
• USG
• CT – Scan
• MRI

52. 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

53. 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

54. • 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

55. 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

58. 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,

59. 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

60. 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

61. 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

62. • 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

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

65. 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

66. 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

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

68. • 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

70. 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

71. • 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

72. 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

73. • 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

74. • 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

75. 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

76. • 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

78. 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

80. • 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

81. 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

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

83. 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

85. • 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

87. 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

88. • 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

89. 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

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

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

92. References ..
• Tuberculosis of the skeletal system – SM Tuli 4th
ed
• TB Hip – current concepts review- Shyam kumar
Saraf,SM Tuli –IJO Jan 2015/vol 49/issue 1
• Tuli SM.MDR TB –A challenge in clinical
orthopedics. IJO2014;48;235-7
• TB of Musculoskeletal system – David
A.Speigel,Girish.K.Singh,Ashok k .Bansota –Tech
in Orthopedics20(2);167-178,2005

93. • Evaluation of clinico-
radiological,bacteriological,serological,molecular and
histological diagnosis of OA –TB –Anil k Jain,Santosh
kumar Jena,MP singh- IJO-April-June
2008/volume42/issue2
• WHO-Global Tuberculosis report-2014
• Campbell’s operative Orthopaedics -12th ed
• Pathological basis of disease- Robbins & Cotran -8th ed
• Color atlas of clinical orthopaedics-Milkos
Sezendroi,Franklin H Sim,2009
• National health programs of india – J. Kishore, 11ed
• Harrison’s Principles of internal medicene -18th ed