Tuberculosis of hip joint

Osteoarticular Tuberculosis is still common in India,with Hip joint being the 2nd commonly involved site

1. TUBERCULOSIS of HIP JOINT Dr.T.Anil kumar 2 nd Year Postgraduate Department of Orthopaedics siddssidd Siddhartha Medical College Vijayawada,AndhraPradesh

2. Historical aspects ROBERT KOCH discovered Mycobacterium tuberculosis in 1882

3. Introduction TB Hip – 2 nd only to spine Spine:Hip ratio – 10:7 Osteoarticular TB – 1-3% of all TB cases ,of which TB hip – 15-20% Primary focus THR in active stage of disease –another area of controversy

4. Organism Mycobacteria belong to the family- MYCOBACTERIACEAE Order – ACTINOMYCETALES M.tuberculosis complex- - M.tuberculosis – m/c human pathogen - M.bovis -bovine tubercle bacillus - resistant to Pyrazinamide - transmitted by unpasteurised milk - M.caprae,africanum,microti,pinnipedii,canetti

5. Organism .. M.tuberculosis - rodshaped,gram positive nonsporeforming , thinAEROBICbacilli 0.5µm × 3µm Once stained ,the bacilli cannot be decolorised by acid alcohol- thus called ACID FAST BACILLI Acid fastness is due to high content of MYCOLIC ACIDS,long chain cross linked fatty acids,other cellwall lipids

6. Organism - Structure In the cellwall,lipids ( mycolic acids) are linked to underlying ARABINOGALACTAN & peptidoglycans Low permeability of cell wall Reduced effectiveness of most antibiotics Genome comprises 4043 genes encoding 3993 proteins,50 genes encoding RNA’s

7. Pathogenesis & Pathology Primary focus (Active/ quiscent,Apparent /latent) Hematogenous dissemination 2-3 yrs Osteoarticular TB

8. Organism reaches joint space through either Subsynovial vessels Lesions in the epiphyseal bones Articular cartilage destruction begins peripherally TB Arthritis- doesnot form proteolytic enzymes in joint space central areas of articular cartilage preserved for long time

9. Common sites.. Initial focus may start in Acetabular roof –m/c Epiphysis/Femur Head Metaphyseal region Greater trochanter -least common

10. TB of GT may involve the overlying trochanteric bursa witout involving the hip joint for a very long time Upper end of femur – intracapsular – joint involved rapidly When initial focus starts in acetabular roof- joint involvement is late ,symptoms mild

11. Tubercle/ Granuloma formation... Initial stages of infection- usually asymptomatic 2-4wks after infection- 2 host responses 1.Macrophage activated CMI: T-cell mediated response Activation of macrophages Killing & digesting tubercle bacilli 2.Tissue damaging response DTH to various bacillary antigens - Destroys unactivated macrophages that contain multiplying bacilli

12. Insemination of infection Accumulation of macrophages/ monocytes TB bacilli – phagocytosed,broken down Lipid dispersed throughout the cytoplasm EPITHELOID cells – large pale cells large vesicular nuclues Abundant cytoplasm LANGHANS GAINT cells

13. Mass formed by reactive cells - Nodule/ TUBERCLE 2wks central CASEOUS NECROSIS Presence of caseous necrosis – SOFT TUBERCLE No caseous necrosis – HARD TUBERCLE Rx, Atypical organism

14. Cold Abscess Collection of products of liquefaction & reactive exudation Contains - serum, leukocytes, caseous material, bone debris,TB bacilli Feels warm ,but temperature not raised as high as in acute pyogenic infection Bursts Sinus/ulcer formation

15. Cold abscess forms within the joint – inferior weaker part of the capsule Perforated Cold abscess presents anywhere around the hip – femoral triangle Medial,lateral / posterior aspect of thigh Ishcio rectal fossa Pelvis

16. Intra pelvic abscess Below the levator ani Above levator ani Ischiorectal fossa Upwards into inguinal region

17. Types of Disease CASEOUS EXUDATIVE More destruction More exudation & abscess formation Insidious onset Marked constitutional features GRANULAR Less destruction Abscess formation rare Insidious onset & course DRY lesion

18. Fate of tubercle Resolve completely Heal completely with residual deformities/ loss of function Lesion completely walled off,caseous tissue – calcified Low grade chronic fibromatous , granulating & caseating lesion may persist Infection spreads – contiguous,systemically

19. Clinical features.. Commonest age : 1 st 3 decades Limping – earliest,commonest symptom - Antalgic gait Pain – reffered to medial aspect of knee - max towards end of the day Deformity Fullness around the hip Night cries sleep awakening

20. Classification

21. Synovitis stage.. Position of max joint capacity – FABER Apparent LENTHENING Only extremes of movement are painful DD – Traumatic synovitis - Nonspecific Transient Synovitis - Low grade pyogenic infection - Perthes disease - SCFE USG repeated at 2-3 wks X-Rays: soft tissue sweling,Rarefaction

22. Early Arthritis stage.. Articular damage starts Severe muscle spasm- FADIR Apparent shortening Restriction of movements in all directions Appreciable muscle wasting MRI – synovial effusion - minimal ares of bone destruction - osseous oedema X-Rays: OSTEOPENIA , marginal bony erosions NORMAL JOINT SPACE

23. Advanced Arthritis .. FADIR True shortening severity of symptoms Capsule further dstroyed ,thickened & contracted X-Rays : Destruction of articular surface Joint space

24. Advanced arthritis with Subluxation / Dislocation With further destruction of acetabulum , femur head ,capsule & ligaments the upper end of femur is displaced upwards & dorsally in the wandering / migrating acetabulum leaving its lower part empty & broken – Pathological dislocation of femur head Movements are grossly restricted

25. Classification - Radiological appearence Shanmugasundaram in 1983 classified the radiological appearences as Type 1 - normal (C) Type 2 – T ravelling/ wandering acetabulum (C,A) Type 3 – D islocating type(C) Type 4 – P erthes type(C) Type 5 – P rotrusio acetabuli (C,A) Type 6 – A trophic(A) Type 7 – M ortar & P estle type(C,A)

26. Shanmugasundaram’s Classification

27. PROTRUSIO TYPE ATROPHIC TYPE

28. If the disease occurs during chilhood Chronic hyperaemia Enlarged femoral head epi & metaphysis COXA MAGNA Thrombo embolic phenomenon of selective terminal vasculature changes similar to PERTHES disease a)Gross blood supply of femoral head due to TE b) Rapidly developing tense IC effusion ( Tamponade effect) reduced femoral head & neck size COXA BREVA

29. Restricted growth of epiphyseal plate & normal trochanteric growth plate COXA VARA Restricted trochanteric growth & normal femoral head COXA VALGA

30. Close relationship b/w radiological type & therapeutic outcome: Normal type - 92% good results Perthes type - 80% good results Dislocating type – 50% good results Travelling acetabulum & Mortar pestle type - 29% good results

31. Evaluation Hematological – ESR,relative lymphocytosis Bacteriological –AFB staining & C/S Serological – ELISA –serum IgG,IgM Histology – HPE for ‘ TUBERCLE ‘ Molecular – PCR using 16sr RNA Clinico –radiological : X-Rays, CT Scan MRI USG

32. Synovial fluid aspiration AFB positive in 10 – 20% of cases Cultures positive in 50% of cases Aspiration of cold abscess for microbiology Synovial Biopsy More reliable Cultures positive in 80% cases Histology : granulomatous inflammation

33. Hip joint aspiration..

34. Bacteriological diagnosis.. Specimen stained for AFB & C/S Stains used: - ZIEHL NEELSEN stain - Auramine Orange fluorescence Media used for growth: Lowenstein- Jensen Conventional AFB C/S – 4wks - requires live organism - long incubation period - low sensitivity in pts already on ATT Newer rapid culture tech- BACTEC

35. BACTEC : Radiometric culture system Detects Mycobac as early as 7-14 days Based on release of radiolabelled CO2 from the growth of Mycobac in selective LIQUID media using C14labelled sustrate

36. Diagnosis – Clinico radiological in endemic areas Paucibacillary Disease – Bacteriological diagnosis is possible in 10-30% cases only HPE & PCR – diagnostic Emerging MDR strains – threat to cure the TB lesion , thus TB bacilli should be isolated & subjected to drug susceptibility

37. Serology.. IgM – diagnostic of activity of the disease IgG – diagnostic of chronic disease/healed disease - levels remain high even after full Rx ELISA antibody values are dependent on - time of taking sample - state / phase of the disease Antibody titres donot correlate with recovery status of the patient.

38. Molecular diagnosis.. PCR – single test which amplifies the genome even if a single organism was present Ideal for detection of paucibacillary TB case Many target genes of Mycobacteria 16sr RNA – used as target sequence as it is universally present false negative - genus specific marker

39. Advantages of PCR.. Highly efficient & rapid method for Dx – 3days Great value in early Dx Very sensitive tech – could detect as few as 1-2 mycobac in the specimen , and Rx initiated based on this result if clinical signs of disease present Can differentiate typical from atypical mycobac Requires very small quantity of specimen – even microlitres of FN aspirate can be tested

40. Disadvantages .. Notable to differentiate live from dead org, as it is not dependent on bac replication Doesnot tell about the activity of the disease PCR positive results doesnot always confirm to culture results PCR – not a substitute for culture

41. Culture – gold standard CT guided FNAC – useful & minimally invasive method of ascertaining HP Dx Screening tests : Tuberculin skin test/ Mantoux test Interferon gamma release assay (IGRA)

42. Tuberculin skin test.. Purified protein derivative (PPD) of tuberculin (Antigenic culture extract) injected intradermally 0.1ml into volar / dorsal aspect of forearm(0.1ml = 0.0002mg PPD) Results read after 48-72 hrs Positive : > 10mm induration Measures delated hypersensitivity

43. Causes of false negative PPD test : Age > 70 yrs Steroid use( Prednisolone >15mg/day) Hypoalbunemia (<2g/dl) Azotemia Impaired cellular immunity HIV infection

44. IGRA.. Measures the release of IFN – Υ by mononuclear cells stimulated by specific M. Tuberculous antigens Useful test for latent TB Good sensitivity & specificity Particularly helpful in distinguishing TB from non tuberculous Mycobac

45. Radiological .. X-Rays USG CT – Scan MRI

46. Management.. Early diagnosis , effective chemotherapy – vital to save the joint Depends upon the stage of clinical presentation Rx includes : ATT Absolute bed rest Traction Excision Arthroplasty Arthrodesis THA

47. Traction.. Prevents /Corrects the deformity Rest to the part Relieves muscle spasm Maintains joint space Minimises development of migration of acetabulum - B/L traction – if abduction deformity, to stabilise the pelvis

48. After 4-6 months of Rx – Ambulation with crutches / orthosis Ambulation : - 1 st 12 wks – non weight bearing 2 nd 12 wks – partial weight bearing Unprotected wt bearing – 18-24 months after onset of Rx

49. CATEGORY TYPE OF PATIENT REGIMENS DURATION 1.New Cases New sputum smear + Seriously ill ,sputum – ve Seriously ill ,EP Sputum negative EP not seriously ill 2(HRZE)3 + 4(HR)3 6 MONTHS 2.Retreatment cases -sputum positive relapse -sputum positive failure -sputum positive treatment after default -2(HRZES)3+ 1(HRZE)3 -5(HRE)3 8 MONTHS 3.MDR TB Cases 6(9)K O Et C Z E / 18( O Et C E ) 24 – 27 MONTHS

50. MDR – TB MDR –TB : Bacteriological Dx If the infecting organism is resistant to INH Rifampicin with/without resistance to other ATT XDR-TB : MDR –TB strains resistant to FLUOROQUINOLONES & one of the Injectables – Kanamycin,Amikacin ,

51. Resistant /therapeutically refractory case : In clincal orthopedics – No response to ATT / No progressive healing Destructive process Continuing discharging sinuses , ulcers New cold abscess apearence size of existing cold absces

52. Rx for Drug resistant TB Isolated INH resistance –Rx : Rifampicin Pyrazinamide Ethambutol –9M Isolated Rifampicin resistance – m/c in HIV pt Rx – several combinations for extended period( upto 18 months) Isolated Pyrazinamide resistance – Rx: INH, rifampicin for 9 months

53. Rx of MDR – TB Initial phase – 5 drugs – 6months Continuation phase – 4 drugs – 18 months 6 ( K O Et C Z E )/18 (O Et C E) K – kanamycin ,O – ofloxacin , Et - Ehionamide C – Clycloserine,Z – Pyrazinamide , E - Ethambutol

54. Rx of XDR – TB : Higher generation FLUOROQUINOLONES are added to the core regimen LEVOFLOXACIN – fluoroquinolone of choice Most forms of EPTB are adequately Rx with INH & Rifampicin 9-12 months course for TB meningitis POTT’S disease Any EPTB that remains culture positive longer than expected

55. Rx – Synovitis stage Chemotherapy – ATT Bed rest Traction Mobilisation exercises prognosis – very good Surgical intervention – usually not required

56. Rx – Early Arthritis Chemotherapy – ATT Traction Analgesics supplementation Non wt bearing ROM exercises started as permitted Synovectomy & joint debridement Passive exercise pain,spasm . Thus avoided Prognosis in general - good

57. Rx – Advanced Arthritis All above & ARTHROLYSIS –subtotal excision of pathological contracted fibrous capsule Useful where limitation of movements is due to FIBROUS ANKYLOSIS Aim – To achieve useful ROM Posterior capsule undisturbed – vital blood supply

58. Rx – Advanced arthritis with subluxation / dislocation Conservative traction regimen If sound ankylosis ,in bad position – upper femoral corrective osteotomy Excision arthroplasty Arthrodesis Hip replacement

59. In advanced arthritis usual outcome- FIBROUS ANKYLOSIS Once fibrous ankylosis – anticipated / accepted – limb is immobilised in HIP SPICA for 4-6 months Ideal position for ankylosis : Neutral position b/w abduction & adduction 5-10 deg of external rotation Flexion depending upon age :children- 10 deg adults – 30 deg

60. Arthrodesis .. Offered only for pt > 18yrs age Types : 1.Intra articular 2.Extra articular – if Adduction – Ischio femoral - if abduction – Ilio femoral 3.Combined intra –extra articular

61. During extra articular arthrodesis ,upper femoral corrective osteotomy can also be performed – brings limb into functional position Intraarticular arthrodesis permits Exploration of joint Excision of diseased tissue Curretage of juxta articular infected tissue

62. Operative tech – IA arthrodesis Standard anterolateral approach Grossly diseased capsule,synovium removed Joint dislocated carefully Excise cartilage , subchondral bone from femoral head & acetabulum down to cancellous bone Repose the rawed head into freshened acetabular cavity,place cancellous bone graft all around the joint

63. Keep the joint in best functional position & insert 2-3 long steinmann pins from base of GT – femoral neck & head – going into acetabulum Apply hip spica After 6-8wks pins removed Gradual Wt bearing with POP on, is started using crutches Immobilisation & wt bearing continued for 4-6 months

64. Very difficult to perform conventional arthrodesis if extensive destruction / sequestration of femoral head & neck Rx – ABBOTT –LUCAS tech of fusion of hip in 2 stages

65. Abbott & Lucas arthrodesis Can be done in active infection ATT cover is mandatory 1 ST STAGE : Anterior Smith –Peterson approach Remove capsule & debride joint Remove femur neck stump& denude GT Debride GT & acetabulum to bleeding cancellous bone, then place GT into acetabulum with limb in wide abduction 30-90 deg abduction may be necessary, av -45deg

66. 2 nd STAGE : 4-8 wks later, osteotomy carried abt 5 cm below LT through lower end of previous incision Distal fragment is usually displaced slightly medially to allow a part of proximal fragment to fit into medullary canal of distal fragment Apply hip spica which is removed after consolidation

67. Brittain’s tech of EA arthrodesis Expose proximal femur laterally,stay out of involved joint capsule Perform subtrochanteric osteotomy angling upwards towards ischium beneath the involved acetabulum With a currette,fashion a hole in the ischium below the involved hip joint capsule & drive the tibial graft across osteotomy site into ischium

68. No internal fixation is used Hip spica applied After 8 th wk post op – walking is undertaken in the cast for upto 6months till fusion occurs

69. Disadvantages of arthrodesis Early development of degenerative osteo arthrosis in LS spine,ipsilateral knee, contralateral hip Compensation for fused hip : Rotation of pelvis flexion of ipsilateral knee during stance phase

70. Activities max limited after fusion bending,sitting on floor, cross legged sitting , Squatting,kneeling,bicycling Thus no pt would accept a fused joint

71. Excision arthroplasty .. GIRDLESTONE – described excision of femoral head,neck,proximal part of trochanter & acetabular rim for chronic dep seated infections of hip joint Can be safely carried out in healed / active disease after growth completion Provides – mobile ,painless hip with control of infection ,correction of deformity

72. Some degree of SHORTENING, INSTABILITY Mean loss of length – 1.5 cm Shortening by postop prolonged TRACTION in 30-50 deg of abduction upto 3months TECTOPLASTY – improves instability MILCH - pelvic support osteotomy at the level of ischeal tuberosity ,also reduces instability

73. Hip replacement in TB .. THA in active infection – controversial due to risk of reactivation Most authors suggest THA atleast 5-10 yrs after the last evidence of active infection Reactivation of infection - 10-30% cases THA in healed TB Hip is now accepted Majority perform it in the stage of advanced arthritis / its sequelae , when joint is unsalvageable

74. Wang et al – combination of ATT for atleast 2wks preop & for atleast 12months post op - THA in advanced active TB hip is a safe procedure with symptomatic relief & functional improvement Sidhu et al – THA in active TB Hip is a safe procedure when perioperative ATT was used - adequate surgical debridement , ATT Key for successful outcome Kim et al – no difference in reactivation / healing with cemented / cementless implants

75. Rx in chidren .. Synovitis & early arthritis – ATT - Traction - bed rest - supportive Rx Management in advanced joint destruction , wandering acetabulum,or with pathological subluxation is difficult & controversial

76. Rx in children.. In children with arthritis –Traction failure Open arthrotomy Synovectomy Debridement of diseased joint Arthrodesis deferred till growth completion

77. In children with healed disease & gross deformity ,(flexion -30,Adduction >30, Abduction >10 deg) extra articular corrective osteotomy

78. References .. Tuberculosis of the skeletal system – SM Tuli 4 th ed TB Hip – current concepts review- Shyam kumar Saraf,SM Tuli –IJO Jan 2015/ vol 49/issue 1 Tuli SM.MDR TB –A challenge in clinical orthopedics . IJO2014;48;235-7 TB of Musculoskeletal system – David A.Speigel,Girish.K.Singh,Ashok k . Bansota –Tech in Orthopedics20(2);167-178,2005

79. Evaluation of clinico-radiological,bacteriological,serological,molecular and histological diagnosis of OA –TB –Anil k Jain,Santosh kumar Jena,MP singh - IJO-April-June 2008/volume42/issue2 WHO-Global Tuberculosis report-2014 Campbell’s operative Orthopaedics -12 th ed Pathological basis of disease- Robbins & Cotran -8 th ed Color atlas of clinical orthopaedics- Milkos Sezendroi,Franklin H Sim,2009 National health programs of india – J. Kishore , 11ed Harrison’s Principles of internal medicene -18 th ed