TUBERCULOSIS OF HIP

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TUBERCULOSIS OF HIP
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TUBERCULOUS ARTHRITISOF HIP
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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

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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

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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

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Staging

• Stage III (Advanced arthritis)
• Deformity, destruction shortening as in II but
  more marked
• Movement loss gt 75
• Capsule is destroyed,thickened and contracted.
  
• X-ray Accentuated findings than II

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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
• Shentons line broken.

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• 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.

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Other Complication

• Soft tissue complications - Abscesses
• Sinuses
• Bony complication
• Coxa Magna
• Growing stage hyperemia
• Coxa valga with increased anteversion of neck
• Acctabular dysplasia
• Frame Knee
• POP for gt 12 Mths.
• Premature fusion of growth plates leads to marked
  shortening and limitation of movements.
• Coxavera fragmentation and flattening of
  femoral head (Perthes type)

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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

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Management

• Investigations
• General Hb,TLC,DLC,ESR,PPD
• Specific
• Radiological
• X-ray/ Sinogram
• Ultrasound
• CT Scan/ MRI

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• 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

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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

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Treatment

• Mechanical support
• Splints Plasters
• Traction ( at times bilateral)
• To relieve spasm
• Correct the deformity
• Joint surfaces apart
• Physiotherapy with traction on

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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

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• 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.

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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.

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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.

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

• Arthrodesis
• Lumbosacral spine,ipsilateral knee and
  contralateral hip should have normal range of
  motion.
• Done only in patients gt18 years of age
• Arthrodesis 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 .

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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)

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Brittains 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.

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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.

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• Interpositional (Amniotic Memb.)
• Total hip replacement
• Atleast after 10 years of last evidence of
  active infection.
• Reactivation recorded in 10-30 of cases.

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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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Thank You