Tb hip

tb hip

1. TUBERCULOSIS OF
HIP JOINT

2. INTRODUCTION
Next to spine, hip joint is the most
common site for involvement by
tuberculosis.
Mostly common first 3 decade of life like
other osteo – articular disease.
It constitute 15 percent of osteoarticular
tuberculosis.

3. 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 .

4. 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 )

5. 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

6. During changing of bed patient may support the involved
limb with contralateral normal limb. Or pt can “apply
traction” on the painful hip on the dorsum of foot by
contralateral limb
8 % patient may have palpable cold abcess with or
without sinuses .
10% present with pathological sublaxation or dislocation
Typical antalgic gait

7. STAGES OF T.B. HIP

8. STAGE 1- (synovitis )
Synovitis with effusion into the cavity.
The hip joint assumes the position of mximum capacity –
FABER --flexion, abduction and external rotation causing
apparent lengthening
Pelvic tilt downwards which cause apparent lengthening of
affected limb
Increased lumbar lordosis
Other local signs are warmth, tenderness, muscle spasm and
painful limitation of all movements of the joint
D/D – traumatic synovitis , rheumatic , non specific transient
synovitis , perthes ds , low grade pyogenic infection

9. If disease is untreated and the patient is bed-ridden
destructive process spreads to the articular surface
Limb assumes the position of flexion, adduction
( apparent shortening )and internal rotation ( FADIR )
due to spasm of adductors
True shortening not more then 1 cm because ht of
articular cartilage is one cm
There is marked muscle wasting of gluteal muscle
Cold abscess formation occurs
X – ray – localized osteoporosis , decrease in joint space
due to decrease in ht of articular cartilage , localize
erosion of articular cartilage .
STAGE 2- (early arthritis )

10. Stage 3(advanced arthritis)
Clinical sign of stage 2 is exaggerated
Gross destruction of articular cartilage and
femoral head and acetabulam

11. STAGE 4(advanced arthritis with
subluxation or dislocation )
With further destruction of capsule and ligaments head of
the femur and may shift upwards and dorsally
Wandering or migrating acetabulum
Dislocation or subluxation may
Protrusion acetabuli occur
Mortar and pestle appearance ( collapse and small femoral
head and neck lie in enlarged acetabulum )
Adduction, flexion and internal rotation gets exaggerated
There is real shortening of limb
Cold abscess bursts and there are sinuses discharging thin
pus

12. Hip may not assume the posture of triple
deformity of F- AD – IR instead hip may assume F
– AB – ER . This may be due to continuous
adoption of of lateral aspect of thigh of diseased
hip resting on bed or due to destruction of ilio –
femoal ligament
If limb has been plastered more than 12 month as
in first half of twentieth century growth plate
around the knee may get closed – frame knee
Coxa megna , coxa vulgus , coxa vara

13. RADIOLOGICAL FEATURES
STAGE 1- generalised
rarefaction of of bones.
Joint space appear
widened due to effusion
STAGE 2- erosion of the
articular surface and
narrowing of the joint
space
STAGE 3- destruction of
head of femur,
dislocation of hip and a
break in the shenton’s
line

14. Radiological type of tuberculosis
(acc to Shanmugasundram)
Type 1 – normal ( C )
Type 2 – migrating acetabulum ( C, A )
Type 3 - Pathological dislocation ( C )
Type 4 – perthese disease ( C )
Type 5 – protrusion acetabula ( C , A )
TYPE 6 – atrophic type ( A )
Type 7 – mortar and pestle appearance ( C ,
A )

15. Hyperamia – large head and neck – coxa megna
Thromboembolic phenomina – perthese disease
Coxa breva due to dec . In blood supply
Restriction growth of capital femoral epiphyseal
plate and normal trochanteric physis – coxa
vara
Normal growth of capital femoral epiphyseal
plate and Restriction
trochanteric physis – coxa vulga
If joint space is reduced > 3mm – poor prognois

16. Differential diagnosis
Transient synovitis
Monoarticular rheumatoid arthritis
Subacute arthritis
Haemorrhagic arthritis
Pyogenic arthritis
Perthes disease

17. CONSERVATIVE MANAGEMENT
Antituberculous chemotherapy is started
Local treatment depend upon stage of disease
EARLY STAGE – Traction is given to correct
deformity and to give rest to the part. Traction
relieves muscle spasm and maintains joint space.
Any palpable cold abscess should be aspirated with
instillation of streptomycin. Active assisted
movement should be started as soon as pain
subsides.After 4-6 months ambulation on suitable
caliper or crutches

18. Advanced arthritis- The usual outcome is gross
fibrous ankylosis.
Initial traction regime help to overcome
deformity and returns any useful range of
motion.
Once gross ankylosis is anticipated the limb
should be immobilized in hip spica.
The ideal position is neutral between abduction
and adduction,5-10 degree external
rotation,and flexion between 10degree in
children to 30 degree in adults.

19. PROGNOSIS
Early anti TB drugs – good prognosis
Early disease ( synovitis and early arthritis ) –
good prognosis
Advanced arthritis – fibrous ankylosis
TB may interfere blood supply of head – same as
perthese disease – should be treated like
perthes disease with antituberculer coverage

20. MANAGEMENT

21. All patient with active disease –
multi drug therapy
traction to correct the deformity
rest to the part
nutrition
In presensce of abduction deformity , for better control of
pelvis b/l traction is mandatory otherwise abduction
deformity will increase .
Any palpable cold abcess – aspiration and installation of
streptomycine + / - isoniazide

22. Favourable response -
Continue same treatment -
if there is no gross ankylosis – active assisted movement
as soon as possible ( sit and touch his fore head to knee ,
squatting , putting the thigh in abduction and external
rotation ) – after 6 month non weight bearing – after 12
wks partial weight bearing – after total 12 month crutch
and orthosis may be discarded – unprotected weight bearing
after 18 to 24 month
If response is not favourable to non – operative
treatment then – synovectomy or debridement

23. advanced arthritis
the usual out come is fibrous ankylosis
traction and functional exercise to gain
correct deformity and gain some useful range of
motion

if ankylosis is anticipated ideal position for hip is
neutral position between adduction and abduction ,5 –
10 degree of external rotation , 10 degree in child and
30 degree flexion in adult for 4 – 6 month -- partial
weight bearing for nearly two year ,

24. Stage of disease and surgical
procedure

25. Synovial stage
Synovitis - If disease not responding or diagnosis not
confirm – arthrotomy , synovectomy
Arthritis – arthrotomy , synovictomy + removal of
loose body / rice body , debris , pannus , loose
articular cartilage , curettage of osseous juxta –
articular cartilage
Post operative – triple drug + traction +
intermittent exercise for 4 – 6 weeks

26. Advance arthritis
Anti tubercular drug – traction - ROM exercises
– some pt maintain good functional range of
movement
When ankylosis is expected or aim then hip
should be immobilized in neutral between
adduction and abduction 10 – 15 degree
external rotation 30 degree flexion in adult and
10 degree flexion in child because younger
spine could compensate more for loss in flexion
at hip joint

27. Healed status of disease
Depending of socio – economic status and facility
available
 upper femoral corrective osteotomy –
sound ankylosis in bad position
extra – capsular
ideal site as close to deformed joint as possible

28. Arthrodesis –
unsound ankylosis with healed or
active disease
deferred till the bone of hip has
growth potential
extra articular arthrodesis –
ischeofemoral or iliofemoral arthrodesis
intra articular arthrodesis –with
modern anti tubercular drugs , between
raw surface of femoral head and
acetabulam

29. Excision arthroplasty
Girdelstone’s excision arthroplasty –
can be done in active and healed stage
after the completion of growth potential
Provide painless , mobile joint and control of infection
and correction of deformity
However there is shortening of 3.5 – 5 cm and instability
which can be reduced by post op traction( 3
mnths ) .
With long term follow up improvement in bone texture
and remodelling and false joint formation .

30. Joint replacement
After maintaining 5 yrs. of healed
status
After replacement 5 months anti
tubercular drugs
Still reactivation occure in 1/3
patients