Tuberculosis of the Hip

Introduction
Tuberculosis (TB) of the musculoskeletal system  1-3% of total
TB cases
TB of hip constitutes 15-20% of the musculoskeletal system
Main symptoms  painful hip, Accurate diagnosis??  Several
pathologies mimic this disease :
1. In children  Perthes disease, juvenile rheumatoid arthritis,
transient synovitis, bleeding disorders, pyogenic arthritis.
2. In Adult  avascular necrosis (AVN), degenerative and
inflammatory conditions
Pathogenesis and Pathology
Osteoarticular TB is secondary to primary pathology in lungs,
lymph nodes or any of the viscera.
Spreading through the hematogenous route  synovium or
bone  the synovial membrane becomes swollen and
congested. Spreading to the bone resulting in necrosis of sub
chondral bone, sequetra and may be kissing lesion on either
side of joint.
Can be extend to the epiphyseal or metaphyseal region
(femur)  Destructive process
Pathogenesis and Pathology
It may start as extra articular or juxta articular lesion.
Cold abscess that usually forms within the joint 
perforate the capsule to present around the hip joint in
the femoral triangle, medial, lateral or posterior
aspects of thigh, ischio rectal fossa
Pathogenesis
and
Pathology
Mycobaterium tuberculosis  lung/gut/skin (rare)  granulomatous reaction 
tissue reaction and caseation

Primary complex (initial lesion) : no clinical illness

Secondary spread : no resistance to the original infection  widespread
dissemination via blood stream
Tertiary lesion: foci developed into destructive lesion
Chronic inflammatory reaction : tuberculous
granuloma/tubercle (multinucleated giant cells
surrounding area of necrosis)
Caseous necrosis  coalesce  abscess containing pus
and fragments of necrotic bone
If unchecked, caseation and infection extend into
surrounding tissue  cold abscess  burst to skin 
sinus/tuberculous ulcer
Origin of Infection in Hip
Clinical Presentation
Pain in the hip Pathological dislocation
Limp Limb attitude  flexion,
Restriction movement adduction, and internal
Deformity rotation
Shortening
Swelling
Sinuses
Investigation
In endemic  Clinical + Radiograph
Classification
Management
Early diagnosis and effective chemotherapy (4 anti tubercular drugs) 
vital to save the joint
Skeletal traction is recommended to all patients
Abduction deformity  traction on the other limb to stabilize the pelvis
Traction relieves the muscle spasm, prevents or corrects deformity and
subluxation, maintain the joint space, minimize the chances of development
of migration of acetabulum and permits close observation of the hip region.
Any palpable cold abscess  aspiration + streptomycin with/without
isoniazid
Favorable clinical response  treatment continued
No gross ankylosis  active assisted movements of the hip
started as soon as possible
After 4 - 6 months treatment  ambulation with suitable
orthosis and crutches
NWB for first 12 weeks
Partial weight bearing for the next 12 weeks
After 18-24 months of treatment  unprotected weight bearing
Nonoperative treatment response unfavorable 
synovectomy or debridement of the diseased joint
Tubercular infection => no proteolytic enzymes are
produced  articular cartilage survives for a long time
thus preserving mobility in many patients.
Partial weight-bearing only after 4-6 months of
treatment, and Full weight-bearing only at 18 months
Weight-bearing earlier, whenever patient can tolerate
the pain  boost patient confidence and activity level
Management in children
Aim of management : painless, mobile hip with anatomy of the
hip joint as near to normal as possible
Late secondary OA is a concern (early detection and management
is important)
Once suspected clinically, radiological examination of hip and
lungs should be analyzed critically.
Investigations  aim to find primary site of lesion
Management in children as in adults depends upon the stage at
presentation
Synovitis and early arthritis  non operative
management.
ATT + skin/skeletal traction
Very young chihld or if joint is very painful : hip spica for
4-6 weeks to reduce the pain
Arthrotomy and surgical debridement  give early
resolution of the disease and take care of deformities
Children with arthritis, deformity and
subluxation/dislocation  traction
Failure to achieve correction  open arthrotomy,
syonvectomy, and debridement
Arthrodesis or excisional arthroplasty should be
deferred until completion of growth potential of the
proximal femur
Disease healed + gross deformity (flexion > 30 deg,
adduction > 10 deg, or abduction > 10 deg) 
extraarticular corrective osteotomy to enable them to
walk better till reach skeletal maturity
If no gross deformity  subtotal excision of the
contracted fibrous capsule (arthrolysis) + traction and
repetitive exercise
Indications for surgical treatment
Osteotomy
Sound ankyloses in bad position  upper femoral
corrective osteotomy

Arthrodesis
Indicated in adult presenting with unsound (painful
fibrous ankylosis) ankyloses with active or healed disease.
Abbott-Lucas’ Technique of Fusion of Hip Joint in
Two Stages
Extensive destruction of head and neck of femur, or prior
arthroplasty has resulted in deficient bone stock  two
stages procedure
Can be done in the presence of active infection or draining
sinus
Anti TB med cover is mandatory
Stage of Disease and Operative Procedure
Synovitis stage:
To establish dx : USG examination  synovial effusion
 aspirated for cytology, AFP smear, and PCR exam
Tissue Biopsy if necessary
Not respond to treatment/diagnosis uncertain 
arthrotomy and synovectomy
Early arthirits
Analgesics supplementation is necessary  until muscle spasm relieved
Non-weight bearing ROM exercise  whenever patient able to cooperate
Failure to treatment respond  confirmation of diagnosis
Synovectomy and joint debridement done with an aim to reduce the
disease tissue load and ascertain diagnosis.
Postop : triple drug therapy, traction, intermittent active and assisted
exercise  4-6 weeks
Ambulation with suitable braces and orthosis (3-6 months post op)
Advanced arthritis:
Clinicoradiological presentation typical of tubercular arthritis :
irregular and hazy joint margins, destruction of bone on either side of joint, erosions and reduced joint
space (Xray)
Gross destruction of capsule, synovium, bones and articular cartilage
+ arthrolysis of joint with joint debridement can be very helpful
Arthrolysis : achieve useful ROM.
Arthrolysis helps in the cases where limitation of movement is because of fibrous ankyloses and not to
mechanical restriction.
Leave the posterior capsule undisturbed  carries vital blood supply to the femoral head
Before completion of the Op  adequate ROM has been achieved by passive movement (under
GA)
After Op  skeletal traction + movement under supervision as soon as patient is able to do
Healed status of disease
May be indicated depend on the socio-economic status of the
patient
Alternative :
Upper femoral corrective osteotomy
Upper femoral displacement-cum-corrective osteotomy in a case
of fibrous ankyloses with gross deformity
Conversion of a painful ankyloses to a sound arthrodesis
Conversion of an ankylosed hip to a mobile state by Girdlestone’s
type excisional arthroplasty or by total joint replacement
Long-standing healed disease and joint
replacement
Joint replacement still debatable
Mandatory to administer modern antitubercular drugs
for about 5 months after any replacement procedure
Advanced arthritis with subluxation/dislocation:
Gross destructive changes  not allow for even functional ROM
The different lines of management of this complex program could
be as follows:
Conservative traction regimen
Healing in 98% of cases by advocating ATT and traction (Sandhu et al)
Patients presenting with sound ankyloses, short fibrous or bony in a
bad position required upper femoral corrective osteotomy (as near the
deformed joint as possible)
Excision arthroplasty
Girdlestone’s excision arthroplasty can be safely carried out in healed or
active disease after completion of growth potential of bones of the hip joint
 provide mobile, painless hip joint with control of infection and
correction of deformity. But shortening and instability unavoidable.
Post operative traction for 3 months minimize shortening and gross
instability

Arthrodesis
Relieves the pain and corrects the deformity – at cost of loss of movements
Hip replacement
no role of hemi replacement
THA  controversial (potential risk of reactivation of TB)
Majority perform in the stage of advanced arthritis or
in sequalae of advance arthritis
To lowering the potential risk of reactivation of TB,
thorough debridement and postoperative
Antituberculosis treatment are the keys
Wang et al : Antituberculous drugs 2 weeks prior to
the operation and at least 12 months after operation.
In healed TB with subluxation/dislocation of long
duration, stability can be provided by tectoplasty.
Prognosis
Outcome of the treatment
depends upon the stage of
the disease at the time of
presentation
“normal” and “perthes”
radiological type  good
prognosis
“travelling acetabulum”,
“dislocation”, “mortar and
pestle” radiological type 
bad prognosis
Surgical Approach to the hip joint
Anterior iliofemoral approach
or anterolateral approach
Transverse anterior approach
 not advised for extensive
reconstructive
procedures/restoration of
anatomy
Alternative approach
Conclusion
TB of hip is still a common condition in developing country
Early presentation : pain around hip and limp
Late presentation : deformities, shortening of limb, and
movement restriction
Diagnosis mainly clinicoradiological
Management depends upon the stage of clinical
presentation and the severity of destruction as visible
radiologically.