Tuberculosis of Hip Joint

Description of tuberculosis hip from the book of sir Tuli. All about the pathology and stages of TB hip.

1. TUBERCULOSIS
OF HIP JOINT

2. CONTENT
Introduction
Pathology
Clinical features
Stages of TB Hip
Radiological features
Differential diagnosis
Management

3. 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.

4. PATHOLOGY
Infection of hip is secondary to
some primary focus either in
lungs or mediastinal node or
iliocaecalregion 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.

5. 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.
TB of greater trochanter may involve the trochanteric bursa without
involving the hip for long time.
As the upper end of femur is entirely intracapsulerthe joint get
involve rapidly and disease become osteoarticular
Cold abcessin joint –perforate inferior weaker part of capsule
rarely acetabular roof –cold abcesscan present anywhere around
the hip ( femoral triangle , medial ,post and lateral side of thigh
,ischeo–rectal fossa , pelvis )

6. 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

7. 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 abscess with or
without sinuses .
10% present with pathological subluxation or dislocation
Typical antalgic gait

8. STAGES OF T.B. HIP
Stage 1: Synovitis
Stage 2: Early Arthritis
Stage 3: Advanced Arthritis
Stage 4: Advanced Arthritis with Sequele

9. STAGE 1: Synovitis
Synovitis with effusion into the cavity.
The hip joint assumes the position of maximum 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

10. STAGE 2: Early Arthritis
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, localized erosion of articular cartilage .

11. STAGE 3: Advanced Arthritis
Clinical sign of stage 2 is exaggerated
Gross destruction of articular cartilage and
femoral head and acetabulum

13. 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 occur
Protrusion acetabulioccur
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

14. 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 lateral aspect
of thigh of diseased hip resting on bed or due to
destruction of iliofemoralligament
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 magna , coxa valgus , coxa vara

15. RADIOLOGICAL FEATURES
STAGE 1-generalised rarefaction 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’sline

16. Radiological type of tuberculosis
(acc. to Shanmugasundram)
Type 1 –normal
Type 2 –migrating acetabulum
Type 3 -pathological dislocation
Type 4 –perthes disease
Type 5 –protrusion acetabula
TYPE 6 –atrophic type
Type 7 –mortar and pestle appearance

23. Hyperemia–large head and neck –coxa magna
Thromboembolic phenomena –perthe’sdisease
Coxa brevadue to decrease 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 valga
If joint space is reduced > 3mm –poor prognosis

24. DIFFERENTIAL DIAGNOSIS
Transient synovitis
Monoarticular rheumatoid arthritis
Subacute arthritis
Haemorrhagic arthritis
Pyogenic arthritis
Perthes disease

25. MANAGEMENT: Forms of
treatment
General
Chemotherapy
Local
Role of surgery

26. Aim of management
Painless
Stable
Mobile
No deformity
No limp
No limb length discrepency

27. Synovitis and early arthritis
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
In presence of abduction deformity , for better control
of pelvis b/l traction is mandatory otherwise abduction
deformity will increase

28. 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,andflexion
between 10degree in children to 30 degree in adults

29. Role of surgey
Synovectomy
Debridement
Arthrodesis
Arthroplasty

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

31. 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 .

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

33. 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