tb hip by dr. hardik pawar

1. TUBERCULOSIS OF HIP
DR. HARDIK PAWAR
CARE HOSPITALS

2. INTRODUCTION
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Oldest disease of human beings
Chronic granulomatous infectious disease
EPTB – 10-15 %
Bone and joint – 1-3 %
Hip joint 2nd most common
M>F
Age group – 20 -30 years

3. HISTORICAL ASPECTS

Robert Koch discovered
Mycobacterium
tuberculosis in 1882.

4. PATHOLOGY
CAUSATIVE ORGANISM
Mycobacterium
tuberculosis.
 SIZE – 3x0.3 um
 Gram positive AFB `
 Hematogenous
dissemination from primary
focus
 Bone & joints TB develop
generally 2-3 yrs after the
primary focus


5. PATHOLOGY
1. TB bacilli phagocytosed
by mononuclear cells
2. Epitheloid cell formation
3.Langhans giant cell formed by fusion
epitheliod cells. Formed only if caseation
necrosis has occurred

6. PATHOLOGY
4.Lymphocytes form a
ring around the lesion
5.Tubercle formation


Epitheloid cells-characteristic of TB.
Presence of caseation necrosis almost diagnostic of TB

7. PATHOGENESIS
Caseous exudative type
• more in children
• more destruction
• more exudation
• abscess formation.
Granular proliferative type
• more in adults
• less destructive
• insidious onset/course
• Cellular proliferation

8. Sites of Hip TB
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Acetabular roof - MC
Epiphysis
Neck/metaphysis
Greater trochanter

9. Disease course
• Initiation of infection
• Joint involvement
• rapid destruction
• cold abscess
»tracks to femoral triangle ,thigh,
ischiorectal fossa, inguinal region
• Joint Distortion , deformity ,
ankylosis

10. Clinical features
• Insidious onset
• Chronic course
• Commonly associated with constitutional
symptoms
• Limp or lameness – earliest and commonest
sign , antalgic gait
• Pain - absent in early stage
• Night cries
• Decreased ROM

11. Cont.
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Fullness around the hip – cold abscess
Deformity - depending on the stage
Wasting of the thigh and gluteal muscle
Limb length discrepency
Due to fixed deformity Secondary chages –
lordosis , scoliosis ,

12. Clinicoradiological staging
1. Stage of synovitis :
• Irritable hip , painful movements
• Flexion , abduction , external rotation .
(FABER ) apparent lenghening.
• X-RAY – soft tissue swelling , haziness of
articular margins & rarefaction
• USG – soft tissue swelling
• MRI – synovial effusion
• Biopsy – can be done for confirmation

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2. Stage of early arthritis :
Destruction of articular cartilage
Spasm of adductors , flexors + wasting
Flexion , adduction , internal roatation
(FADIR) , Apparent shortening
• ↓sed ROM
• X-RAY – osteopenia , erosion of articular
margins , ↓ joint space
• MRI - synovial effusion , edema , minimal
bone destruction

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3. Stage of advanced arthritis :
Further destruction of joint
True shortening > 1 cm
Muscle wasting
Decrease in ROM
X RAY - further decrease in joint space.

18. • 4. Advanced arthritis with subluxation /
dislocation :
• Furhter destruction of acetabulum , head ,
capsule and ligaments.
• Gross restriction of ROM
• Head – upwards and posteriorly
• Wandering / migrating acetabulum
• Mortle & pestle appearance
• Reduced joint space

19. Radiograph showing a ‘travelling’ or
‘wandering’ right hip

20. Radiograph of the LEFT hip showing the
‘mortar-and-pestle’ type lesion

21. CLINICO RADIO LOGICAL
CLASSIFICATION

25. 6 YEAR BOY WITH DISLOCATING TYPE DISEASE

26. Tuberculous of the Hip.
Morphologic changes
“protrusio” type (A)
and an “atrophic” type (B).

27. 2 YEARS BOY WITH PERTHES TYPE DISEASE

28. COXA MAGNA

29. MANAGEMENT

30. INVESTIGATIONS
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CBC
ESR
MANTOUX TEST
TB ELISA
IMAGING : X RAY – HIP
SYNOVIAL BIOPSY
SMEAR , CULTURE AND GUINEA PIG INOCULATION
MRI - EFFUSION , SYNOVIAL THICKENING , JUXTRA
ARTICULAR OSTEOPENIA
PCR – RT PCR , NESTED PCR

31. • X – RAY FINDINGS :
Periarticular osteopenia
Soft tissue swelling
Minimal periostel reaction
Joint space narrowing
Subchondral cyst
Subchondral erosion

32. INVESTIGATIONS
 Sputum examination :
for AFB

33. INVESTIGATIONS

Aspiration of abscess :
smears & culture of pus
CULTURE=GOLD STANDARD
SOLID MEDIA: 3-8 weeks
Lowenstein Jensen (egg Based)
Middlebrook 7H11(agar based)
LIQUID BROTH:
1-3 weeks

34. INVESTIGATIONS

BACTEC media: for faster culture (within 1-2wks)
Bactec 460
Bactec9000MB
Bactec mgit960b

35. AIM OF THE MANAGEMENT
PAINLESS
SYMPTOM FREE
STABLE
FREELY MOBLE
NORMAL GAIT
NO DEFORMITY
NO LLD

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GENERAL
CHEMOTHERAPY
LOCAL TREATMENT
ROLE OF SURGERY

37. GENERAL TREATMENT
GOOD DIET
FRESH AIR
SUNLIGHT
EDUCATION
OCCUPATION

38. CHEMOTHERAPY
• 6-9 MONTH DURATION
• 12 MONTH FOR PEDIATRIC AGE GROUP

39. • 1st line - HRZES
• 2ND Line Capreomycin
Kanamycin
Ethionamide
Cycloserine
PAS
• Newer drugs : rifapentin , rifabutin ,
gatifloxacin , moxifloxacin

40. Bactericidal drugs
1.Isoniazid
2. Rifampicin
Dose
5mg/kg
10-15 mg/kg
3. Streptomycin
20mg/kg
4. Pyrazinamide
20-25 mg/kg
Bacteriostatic drugs
1. Ethambutol
Dose
25mg/kg (x 2mnths)
Then 15mg/kg

41. LOCAL TREATMENT
• A) STAGE OF SYNOVITIS AND EARLY
ARTHRITIS :
ATT
TRACTION
ASPIRATION OF COLD ABSCESS

42. • TRACTION :
Relieves muscle spasm
To give rest to joint
Prevents deformity
Maintain joint space
Minimizes chances of developing migrtaing
acetabulum
• PROTOCOL :

43. • B ) STAGE OF ADVANCED ARTHRITIS :
Traction
Usually gross fibrous ankylosis is out come

44. Role of surgery
• To establish diagnosis
• Therapeutic
• Failure of conservative treatment

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SYNOVECTOMY
DEBRIDEMENT OF JOINT
ARTHRODESIS
ARTHROPLASTY

46. ARTHRODESIS
• Surgical fusion of joint
• INDICATIONS :
Failure of conservative Mx
Relapse
Destructive lesion in head
Painful fibrous ankylosis
Ankylosis with severe deformity

47. • TYPES :
INTRAARTICULAR
EXTRAARTICULAR
COMBINED

48. INTRAARTICULAR
• Active disease
• Painful fibrous ankylosis
• Lower rate of fusion
EXTRAARTICULAR
• ILIOFEMORAL - HIBBS
• ISHIO FEMORAL BRITTAIN’S

50. • ABOTT LUCAS TECHNIQUE :
2 STAGE PROCEDURE
1ST – Arthrodesis in wide abduction
2nd – subtrochantric osteotomy to repostion
limb

51. • BEST POSITION :
30 DEGREES OF FLEXION
5-10 DEGREES OF ER
NO ADDUCTION

52. EXCISION ARTHROPLASTY
HEAD , NECK , RPOXIMAL PART OF TROCHANTER
AND ACETABULAR RIM EXCISED
PAINLESS
MOBILE HIP
PERMITS SQUATTING
BUT
INSTABILITY
SHORTENING

54. REPLACEMENT ARTHROPLASTY
• EARLY CEMENTLESS THR IN ACTIVE TB
PROVIDED PATIENT IS ADMINISTERED ATT
AND THOROUGH DEBRIDEMENT Of DISEASED
TISSUE IS DONE.
• ( ACCORDING TO RECENT AUTHORS )
• Cemented
- Hardinge et al. 1979
- Kim et al. 1988
• Uncemented - Eskola et al. 1988
- Caparros et al. 1999
- Yoon et al. 2001

55. •
Normal hip type tuberculosis lesion of left hip (a, b). Triple chemotherapy for
12 months and bed rest was given. The tuberculosis lesion had healed
without joint damage and sequelae (c)

56. Perthes type hip
epiphysio-metaphyseal tuberculosis of the left proximal femur (a, b).
After joint debridement, the child was immobilized with cast for 6 weeks under
cover of triple chemotherapy (12 months).
Tuberculosis healed without joint destruction,
though residual coxa magna deformity was present (c)

57. Atrophic type tuberculosis of hip in
a 11-year-old girl. There is slight joint space narrowing of left hip (a).
After synovectomy chemotherapy for 12 months was given (b, c, d).
Tuberculosis healed (3 years followup) though atrophic head and neck are seen (d)

58. REFERENCES
1.
Campbell JA, Hoffman EB. Tuberculosis of the hip in children.
J Bone Joint Surg Br 1995;77:319-26.
2. Shanmugasundaram TK. A clinicoradiological classification of
tuberculosis of the hip. In: Shanmugasundaram TK (editor).
Current concepts in bone and joint tuberculosis. Madras,
India: Proceedings of Combined Congress of International
Bone and Joint Tuberculosis Club and the Indian Orthop
Assoc;1983. P. 60.
3. Moon MS, Kim SS, Lee SR, Moon YW, Moon JL, Moon SI.
Tuberculosis of the hip in children: A retrospective analysis. Ind J
Orthop 2012;46: 91-99.

59. • 4.
Eskola A, Santavirta S, Konttinen YT, Tallroth K, Hoikka V,
Lindholm ST. Cementless total replacement for old
tuberculosis of the hip. J Bone Joint Surg (Br) 1988;70:603–
606.
• 5.
Yoon TR, Rowe SM, Santosa SB, Jung ST, Seon JK.
Immediate cementless total hip arthroplasty for the
treatment of active tuberculosis. J Arthroplasty. 2005;20:923–
926. doi: 10.1016/j.arth.2004.08.002.

60. THANK YOU