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Tuberculosis of the hip

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tuberculosis , hip , management

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Tuberculosis of the hip

  2. 2. THE BACILLI • Causative organism: mycobacterium tuberculi • Slow growing aerobic organism with a growth doubling time of 20 hrs in favourable condition. In unfavourable condition the organism will grow only intermittently or will remain dormant for period of time till the host immunity is defecient. • M. tuberculosis has an unusual, waxy coating on its cell surface (primarily due to the presence of mycolic acid), which makes the cells impervious to Gram staining. The Ziehl-Neelsen stain, or acid-fast stain, is used instead. The physiology of M. tuberculosis is highly aerobic and requires high levels of oxygen.
  3. 3. Buff colored , rough colonies
  4. 4. • Ideally , diagnosis of tuberculosis is confirmed on demonstration of the bacilli in skeletal tuberculosis lesion. However , this is not possible in numerous case series because , skeletal tuberculosis is supposed to be a paucibacillary condition. • Bacilli load in osteoarticular TB is less than 105
  5. 5. THE TUBERCLE • The initial response is in the reticuloendothelial depots of the skeletal tissue. • PMNs Macrophages & Monocytes • The tubercle bacilli are phagocytosed and broken down and their lipid is dispersed throughout the cytoplasm of mononuclear cells transforming them into epitheloid cells. • The epitheloid cells fuse together to form the langhans giant cells when caesation occurs.
  6. 6. • Lympphocytes form a ring around the langhans cells with caesation necrosis. • This mass formed by the reticuloendothelial cells together with caseous material is known as the tubercle. • Tubercle with caesation called ‘soft tubercle’ • Tubercle without caesation called ‘hard tubercle’.
  7. 7. TUBERCULAR SEQUESTRA • Osseous destruction occurs by lysis of bone,which softens and yields under gravity & muscle action leading to compression , collapse or deformation of bone. • Necrosis occurs due to thromboembolic phenomenon , endarteritis and periarteritis. • As a result of ischaemic changes , sequestra occurs and appears as ‘coarse sand’ pattern which is radiologically difficult to see.
  8. 8. • Sometimes , the adjacent articular cartilage or disc gets involved and becomes part of the sequestra. • ‘ Feathery Sequestra’ occurs when caseous material becomes calcified.
  9. 9. ‘TB HIP’
  10. 10. EPIDEMOLOGY • Bones and joints and affected in ~5% of pts with TB • Commonest is spinal TB in ~50% of cases • Hip – 15% of all osteoarticular TB • Can occur in any age group but is more common in children. • Next common after spinal TB
  11. 11. PATHOLOGY • M.TB entry – inhalation, ingestion, skin innoculation • Primary complex, secondary spread and tertiary lesion. osseoarticular TB is haematogenus • Always starts in bone, rarely synovium –granulomatous reaction • The anatomical sites of the lesions: 1.The superior rim of the acetabulam 2. Epiphysis 3. Babcock's triangle 4. Greater trochanter. 5. Rarely, purely synovial in location. • In hip joint head and neck are intracapsular so a bony lesion invades the joint early
  13. 13. CLINICAL PICTURE • h/o previous TB infection or contact • Insidious onset, chronic course • Most pts are children • Prior constitutional symptoms • First symptom stiffness of hip with a limp • Pain may be absent in early stages • Pain worse at night – “night cries”
  14. 14. EXAMINATION • INSPECTION - Antalgic / stiff / trendelenberg - Muscle wasting - Discharging sinus / cold abscess - Limb length discrepecency, FFD
  15. 15. • PALPATION - Local tempreature - Pelvic tilt - Tenderness • MOVEMENTS - Restricted movements
  16. 16. STAGES OF TB HIP • STAGE -1 ( STAGE OF SYNOVITIS) - effusion in the joint that demands the hip in position of maximun capacity i.e FLEXION , ABDUCTION & EXTERNAL ROTATION causing APPARENT LENGTHENING
  17. 17. • STAGE -2 (STAGE OF ARTHRITIS) - Articular cartilage is involved leading to spasm of the strong muscles of the hip i.e. the flexors and the adductors. - FLEXION ADDUCTION & INTERNAL ROTATION. Causing APPARENT SHORTENING.
  18. 18. • STAGE – 3 ( ADVANCED ARTHRITIS) - Further destruction of hip elements leading to exaggeration of FADIR , restriction of movements, muscle wasting and limb shortenings.
  19. 19. • STAGE – 4 (ADVANCED ARTHRITIS WITH SUBLUXATION & DISLOCATION) - More destruction of hip leading to displacement of the femoral head in acetabulum leaving its lower part empty and broken shentons arc. - Generally , movements are restricted but gross destruction may cause collapse and certain radiological appearance may retain fairly good ROM.
  20. 20. The subluxated or dislocated hip Occurs due to capsular laxity and synovial hypertrophy
  21. 21. ‘Wandering’ Acetabuli
  22. 22. ‘Mortar & Pestle’
  24. 24. Shanmugasundaram’s classification
  25. 25. IMPORTANT OBSERVATIONS A] Childhood TB hip (growing period) chronic hyperemia would lead to enlargement of femoral head epiphysis and metaphysis leading to COXA MAGNA. B] Thromboembolic phenomena of selective terminal vasculature create Perthe’s like changes and reduced blood supply due to effusion (tamponad effect) causing decrease size of femoral head and neck – COXA BREVA.
  26. 26. C] Restricted growth of femoral capital epiphysis with normal growth of trochanteric growth plate lead to – COXA VARA. D] Restricted growth of trochanteric physis with normal growth of femoral epiphysis lead to - COXA VALGA.
  27. 27. E] A triad of radiologic abnormalities (Phemister triad); – periarticular osteoporosis – peripherally located osseous erosion – gradual diminution of joint space suggests the dx of TB F] Occasionally, wedge-shaped areas of necrosis (kissing sequestra) in joint margin. These marginal erosions may simulate RA
  28. 28. TREATMENT • Rest • Chemotherapy • Arthroplasty • Arthrodesis • Osteotomy
  29. 29. • Thomas urged that TB should be treated by rest – which had to be ‘prolonged, uninterrupted, rigid and enforced’. HUGH OWEN THOMAS
  30. 30. TRACTION –Provides rest to the joint –Relieves muscle spasm –Prevents and corrects deformity –Maintains joint space –Minimises chance of developing wandering acetabulum
  31. 31. CHEMOTHERAPY TB disease category Intensive phase (2 months) Continuation phase (4 months) All forms of PTB and EPTB except TB meningitis and osteoarticular TB 2RHZE 4RH TB meningitis, osteoarticular TB 2RHZE 10RH Courtesy: 2009TBguidelinesbyministryof health
  32. 32. ARTHROPLASTY THR • RESERVED FOR ADULT TB ISSUES • Reactivation of disease • Duration of dz free interval before arthroplasty • Anti-TB use peri-arthroplasty
  34. 34. ARTHRODESIS optimal positioning for function and limited effect on adjacent joints 200 – 350 FLEXION 0 – 50 ADDUCTION 50 – 100 EXTERNAL ROTATION * avoid abduction as it creates pelvic obliquity and increased back pain
  35. 35. BRITTAINS ARTHRODESIS In, TB hip , ischium is not reached in disease progress, thus , extra articular arthrodesis can be done. Used in children with fibrous ankylosis to achieve painless hip. Studies showed upto 88 % favourable results.