TUBERCULOSIS OF HIP

TUBERCULOUS ARTHRITISOF HIP

Clinical Presentation

Common during first 3 decades of life General – As in any tuberculosis infection Systemic- Depending on primary focus Local

Pain- May be referred to knee night cries

- Limp – Earliest & commonest Antalgic Gait

- Swelling – Fullness around hip - Tenderness – Femoral triangle, Gr. Trochanteric (Axial)- Muscle Spasm – All around hip & lower abdomen

Staging Stage I (Of synovitis) - D/D of irritable hip

Joint held in position of maximum capacity FABER ( flexion, abduction and external

rotation) Apparent Lengthening ,no true/real

shortening Only terminal movements restricted and

painful Radiological – Soft tissue swelling only Ultrasound – may help

Staging Stage II (early arthritis)

(Stage of apparent shortening) Local signs more prominent FADIR ( flexion, adduction, internal rotation) True shortening ~ 1 cm. Muscle wasting appreciable Restriction of movements in all direction (25-

50%) X-ray - Erosion of articular margin

- Reduced joint space - Adjacent osteoporosis

Staging

Stage III (Advanced arthritis) Deformity, destruction & shortening as in II but more marked Movement loss > 75%

o Capsule is destroyed,thickened and contracted.

X-ray – Accentuated findings than II

Staging Stage IV (of complications/ of real

shortening) Wandering acetabulum Protrusio acetabuli Mortar & pestle appearance Frank post. dislocation of hip

Clinical & Radiological finding Destruction ileofemoral ligament or postural

prolonged external rotation attitude Shenton’s line broken.

In some cases of aftermath of tuberculous arthritis with the disease healed in displaced position,the femoral head may be supported by a buttress formed over its posterosuperior aspect.

Other Complication

Soft tissue complications - AbscessesSinuses

Bony complication Coxa Magna

Growing stage hyperemia Coxa valga with increased anteversion of neck Acctabular dysplasia

Frame Knee POP for > 12 Mths. Premature fusion of growth plates leads to marked

shortening and limitation of movements. Coxavera – fragmentation and flattening of femoral head

(Perthe’s type)

Prognosis Virulence of organism Host resistance

Age, nutritional status, immunity, concomitant other diseases

Therapeutic intervention• At what stage started • Response to chemotherapy • Supportive conservative,

mechanical & surgical measures

Final outcome• Mobile painless stable hip • Mobile painless unstable hip • Fused painless stable hip

Management

Investigations General – Hb%,TLC,DLC,ESR,PPD

Specific Radiological

X-ray/ Sinogram Ultrasound CT Scan/ MRI

Serological – ELISA, PCR Bacteriological

AFB staining/ Culture & Sensitivity Histopathology/ Aspirate examination

Synovial fluid Polymorpho Leukocytosis (10-20,000) Decrease sugar Increase protein Poor mucin clot

Guinae pig innoculation

Treatment

1. ATT – 4 drug (2 cidal) Intensive phase for first 3 months)

Followed by 3 drugs for next 6 months Followed by 2 drugs for next 18 months or

some time 24 months 2. Nutritional support 3. Analgesics & muscle relaxants 4. Judicious use of steroids 5. Treatment of associated problems

Treatment

Mechanical support Splints & Plasters Traction ( at times bilateral)

To relieve spasm Correct the deformity Joint surfaces apart

Physiotherapy with traction on

Response to treatment

4-6 months of conservative treatment

Favorable response

Non weight bearing ambulation for 6 months

With support partial weight bearing for 6 months

Full weight bearing

In Advance arthritis Usual outcome is Fibrous ankylosis Immobilize in ideal position in POP spica

for 6 months 0-30 degree flexion Neutral adduction/ abduction 5-10 degree external rotation

Followed by walking in spica for 6 months Full weight bearing at 2 yr.

Special considerations in children

Adductor tenotomy & manipulation under GA to correct deformity

Frame knee- take care Arthrodesis of the grossly destroyed hip joint or excisional arthroplasty in children should be deferred till the completion of growth potential.Children presenting with the disease healed with gross deformity require an extraarticular corrective osteotomy.

Surgical intervention Adjuvant to ATT (response to conservative

treatment unfavourable or outcome unacceptable)

Synovectomy & joint debridement Confirms diagnosis, improves circulation & drug delivery If done in time, gives useful range of movement without

pain Along with the hypertrophied synovium,diseased and

thickened capsule may be excised. Can be done without dislocating the hip joint. Possible complications are AVN of femoral

head,slippage of proximal femoral epiphysis in children,fracture of femoral neck or acetabulam.

Corrective osteotomy – Ideal site is as near the deformed joint as possible(Proximal Femoral)

ArthrodesisLumbosacral spine,ipsilateral knee and contralateral hip should have normal range of motion.Done only in patients >18 years of ageArthrodesis can be intraarticular or extraarticular or combined panarticular.In adduction deformity-ischiofemoral,in abduction deformity-iliofemoral extraarticular arthrodesis easy to perform.Best position 30 degree flexion.np adduction or abduction,5-10 degree of external rotation .

Abbott-lucas technique of fusion of hip joint in two stages

Done when there is extensive destruction of head and neck of femur,in deficient bone stock.

When patient prefers strong,fused and painless hip joint.

Can be done in active infections of draining sinuses.

After removing the femoral neck stump,denuded greater trochanter placed into the acetabulum after exposing the cancellous bone in 45 degree of abduction.

Second stage-After four to eight weeks osteotomy is carried out(5cms below the lesser trochanter)

Brittain’s technique of extraarticular fusion of hip joint

Upper femoral osteotomy carried out to correct fixed deformity of the hip joint

Free bone graft is used between the osteotomy and a slot in the ischium.

Arthroplasty

Girdle stone (excisional) Leads to mobile unstable hip joint. Excision of the femoral head,

neck,proximal part of trochanter and the acetabular ring.

Post operatively upper tibial skeletal traction in 30 to 50 deg abduction for 3 months.

Active assisted movement of hip and knee started during 1st week

After 3 months non weight bearing walking.

After 6-9 months walking adviced with the stick in contralateral hand.

Mean loss of length 1.5 cms Sometimes leads to very unstable hip

joint.needs supplementary operations as pelvic support osteotomy at the level of ischial tuberosity(Milch-Bacheolar type)OR pedicle shelf procedure at upper margin of acetabulam.

Interpositional (Amniotic Memb.)

Total hip replacement Atleast after 10 years of last evidence of

active infection. Reactivation recorded in 10-30% of

cases.

Treatment of complication

Sinuses Heal by ATT in 2-3 months If not, excision of tract

Abscesses Aspiration & streptomycin/ INH

injection Evacuation

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