TB HIP JOINT

1. TUBERCULOSIS OF HIP
MODERATOR – DR. NAGAKUMAR JS
PROFESSOR AND HOU
DEPT OF ORTHOPAEDICS
RLJALAPPA HOSPITAL KOLAR
PRESENTER – DR. NANDINI SANJAY
JUNIOR RESIDENT

2. HISTORY
• It has been hypothesized that the genus Mycobacterium
originated more than 150 million years ago
• The illness in the middle ages was known in England and
France as "king's evil", and it was widely believed that persons
affected could heal after a royal touch
• Percival Pott first described TB of spinal column in 1779

3. • “White plague” - during the 18th century
• French physician Laennec, discovered the basic microscopic
lesion – tubercle
• Robert Koch was able to isolate the tubercle bacillus in 1882

4. ORGANISM
• Mycobacterium tuberculosis
• Slow growing
• Aerobic organism
• Growth doubling time – 20 hours
• Skeletal TB – Paucibacillary disease
• Load of M.tb
• Pulmonary lesions – 107 – 109
• Osteoarticular lesions - <105

5. INTRODUCTION
• TB of the musculoskeletal system – 1-3% of total TB cases
• Vertebral TB – mc form of skeletal TB
• TB hip constitutes 15-20% of skeletal TB

6. PATHOGENESIS
Hematogenous dissemination - 1° infected visceral focus
Osteoarticular tubercular lesion
• Vascular channels
• 2-3 years after primary focus
• Disease starts in the bone or the synovial membrane
• One infects the other – uncontrolled disease

7. Tubercular bacilli
via bloodstream
Subsynovial vessels
Joint space
Peripheral Articular cartilage
Ring like granulation tissue (pannus)
Subchondral region
Erosion of margins and surface of articular cartilage
Flakes and loose sheets of necrosed articular cartilage + fibrinous material in synovial
fluid
RICE BODIES

8. Articular surfaces in contact
Ingrowth of tuberculous granulation tissue
Necrosis of subchondral bone on either side of the joint line
Kissing lesion / Kissing sequestrae

9. • Typically starts in the metaphysis in pediatric age group
• May infect the neighboring joint through sub-periosteal space
and capsule or through the destruction of the epiphyseal plate –
shortening or angulation
• In adults – bone ends

10. • Cartilagenous tissue – resistant to tuberculous destruction

11. Tuberculous process reaches the subchondral region
Articular cartilage looses its nutrition, attachment to the bone
Lies free in the joint cavity

12. • Host – good/competent immunity – usually TB synovitis occurs
– course of disease is slow
• Synovial membrane – swollen and congested with synovial
effusion
• Granulation tissue from synovium extends to bone at synovial
reflections – erodes the bone

13. LOCATION
• The initial focus of TB lesion may start in –
• Acetabular roof
• Epiphysis Babcock’s
• Metaphyseal region
• Greater trochanter
• Rarely presents as synovitis of hip joint
• May involve the subtrochanteric bursa without involving the hip
joint

14. • Upper end of femur – intracapsular – rapid involvement of joint
if any osseous lesion within the capsular attachments
• If initial focus starts in acetabular roof – joint involvement is late
and severity of symptoms is mild – patient reports late
• COLD ABSCESS may form – Within the joint and may perforate
through the inferior weaker part of the capsule or rarely through
acetabular floor

15. COLD ABSCESS
• Formed by collection of products of liquefaction and reactive
exudation
• Abscess – serum, leucocytes, caseous material, bone debris
and tubercle bacilli
• May penetrates ligament, bone and periosteum

16. • Migrates along facial planes and along neurovascular bundles
• May burst to form a sinus or ulcer
• Cold abscess may present anywhere around the hip joint –
• Femoral
• Medial, Lateral/Posterior aspects of thigh
• Ischiorectal fossa
• Pelvis

18. CLINICAL FEATURES
• Starts during the first 3 decades
• Active disease –
• Pain, limping, deformity and fullness around the hip
• Pain – referred to the medial aspect of the knee, Night cries
• Limping – Earliest and mc symptom, Antalgic gait

19. PHYSICAL EXAMINATION
• Tenderness
• Muscle spasm
• Local swelling
• Sinus +/-

20. STAGES
I. TUBERCULAR SYNOVITIS
II. EARLY ARTHRITIS
III. ADVANCED ARTHRITIS
IV. ADVANCED ARTHRITIS WITH SUBLUXATION OR
DISLOCATION

21. INVESTIGATIONS
1. XRAYS – of hip joint and chest
• Changes may be visible 2-4 months after onset of disease
2. CT – extent of bone involvement and localization of the lesion
• Small lytic lesions in bone and marginal erosions
• Dystrophic calcification
3. MRI
• Edema of involved bone
• Extent of soft tissue involvement
4. Blood –
• Lymphocytosis
• Low Hb
• Raised ESR and CRP

22. 4. Blood –
• Lymphocytosis
• Low Hb
• Raised ESR and CRP
5. Mantoux test
6. Biopsy
• Examination of synovial joint aspiration –
• Leucocytosis (predominantly PMNs)
• Glucose
• Proteins
• Poor mucin clot
• Core biopsy
• Needle biopsy
• Open biopsy
• Enlarged lymph nodes

23. 7. Smear and Culture – Acid fast bacilli
• Synovial fluid – 10%
• Synovial tissue – 20%
• Regional lymph nodes – 30%
• Osseous cavities and destroyed areas – 10%
8. Isotope scintigraphy - 3 isotopes currently utilized for osseous
TB
• Technetium(99mTc) – most sensitive
• Gallium(67Ga)
• Indium(111In)
• Drawback – Lack of specificity, not diagnostic

24. 9. Serological Investigations
• ELISA
• PCR – Fluid from cold abscess, joint

25. STAGE OF TUBERCULAR SYNOVITIS
• Juxta – articular osseous lesion
• Joint is in Flexion, Abduction and External rotation (FABER)
• Apparent lengthening
• Extremes of movement – limited and painful
• Xrays – soft tissue swelling

26. • USG – swelling of soft tissue around the hip joint
• MRI – synovial effusion and bone edema
• Synovial effusion can be aspirated and sent for cytology, AFB
smear and PCR examination
• Biopsy can be taken from diseased tissue to establish the
diagnosis

28. DIFFERENTIAL DIAGNOSIS AT THIS
STAGE
• Traumatic synovitis
• Rheumatic/rheumatoid disease
• Nonspecific transient synovitis
• Low-grade pyogenic infection
• Perthes’ disease
• Juxta-articular disease causing irritation of the joint
• Slipped capital femoral epiphysis.

29. STAGE OF EARLY ARTHRITIS
• Destruction or damage to the articular cartilage
• Joint is in Flexion, Adduction and Internal rotation (FADIR)
• Apparent shortening
• Appreciable muscle wasting
• Restriction of hip movements due to pain in all directions

30. • Xrays –
• Localized osteoporosis
• Slight reduction of joint space
• Localized erosions of articular margins
• MRI –
• Synovial effusion
• Minimal areas of bone destruction
• Osseous edema

32. STAGE OF ADVANCED ARTHRITIS
• Gross destruction of articular cartilage and femoral head and acetabulum
• Capsule further destroyed, thickened and contracted
• Flexion, Adduction and Internal rotation (FADIR) is exaggerated
• True shortening
• Severe muscle wasting
• Severe restriction of hip movements

33. • Xrays –
• Destroyed and atrophic femoral head
• Obliteration of joint space
• Severe erosion of articular margins

35. STAGE OF ADVANCED ARTHRITIS
WITH SUBLUXATION/DISLOCATION
• Severe destruction of acetabulum, femoral head, capsule and
ligaments
• Upper end of femur is displaced upwards and dorsally
• Wandering/Migrating acetabulum
• Shenton’s arc broken

36. • Frank pathological posterior dislocation of femoral head
• Flexion, Adduction and Internal rotation (FADIR)
• Gross restriction of movement at hip joint
• Protrusion acetabuli
• Coxa breva
• Mortar and Pestle appearance of hip joint

37. • If limb has been plastered for >12 months –
• Growth plate in the knee undergoes premature fusion – marked
shortening and limitation of movements (FRAME KNEE)
• Coxa Magna deformity may occur – due to hyperemia and
overgrowth of femoral head and neck
• Coxa Vara may also occur – destructive lesion in femoral head
and neck(arrested growth of capital physis) with normal growth
of greater trochanter

38. • Adaptive changes in the acetabulum – resembles acetabular
“dysplasia”

40. CLINICORADIOLOGICAL CLASSIFICATION OF TB
HIP
STAGES CLINICAL
FINDINGS
RADIOLOGICAL
FEATURES
I. Synovitis FABER, apparent
lengthening
Soft tissue swelling, haziness of
articular margins and rarefaction
II. Early arthritis FADIR, apparent
shortening
Rarefaction, osteopenia, marginal
bony erosions in femoral head,
acetabulum or both. No reduction in
joint space
III. Advanced arthritis FADIR, true shortening All of the above and destruction of the
articular surface, reduction in joint
space
IV. Advanced arthritis
with
FADIR, gross shortening Gross destruction and reduction of
joint space, wandering acetabulum

41. SHANMUGASUNDARAM
CLASSIFICATION
• Radiological classification of TB hip in children(C) and adults(A)
–
1. Normal appearance (C)
2. Travelling acetabulum (C,A)
3. Dislocated hip (C)
4. Perthes’ type (C)
5. Protrusio acetabuli (C,A)
6. Atrophic type (A)
7. Mortar and Pestle type (C,A)

42. NORMAL TRAVELLING
ACETABULUM
DISLOCATING
PROTRUSIO
ACETABULI
ATROPHIC
PERTHES TYPE MORTAR &
PESTLE

50. RELATION BETWEEN RADIOLOGICAL
TYPES AND FUNCTIONAL OUTCOME

51. CAMPBELL AND HOFFMAN’S
PROGNOSTIC PREDICTORS
RESULT
S
DESCRIPTION POPULATION
(%)
GOOD
NORMAL 92
PERTHES’ TYPE 80
DISLOCATING TYPE 50
TRAVELLING ACETABULUM + MORTAR-
PESTLE TYPE
29
POOR JOINT SPACE <3mm -

52. CHILDHOOD
C/H Hyperemia
Enlargement of femoral head epiphysis and metaphysis(COXA
MAGNA)
Thromboembolic phenomenon of selective terminal vasculature
Changes resembling Perthes’ ds, rapidly developing tense
intracapsular effusion
Gross decrease in blood supply to the femoral head and its physis
COXA BREVA/COXA VALGA

53. MANAGEMENT

54. ANTI-TUBERCULAR TREATMENT
• All cases of bone and joint TB should be treated with extended
courses of ATT with – 2HRZE/10HRE
• 2-month intensive phase consisting of four drugs
1. Isoniazid (H)
2. Rifampicin (R)
3. Pyrazinamide (Z)
4. Ethambutol (E)
• Followed by a continuation phase lasting 10–16 months,
depending on the site of disease and the patient’s clinical
course with HRE
INDEX-TB GUIDELINES - Guidelines on extra-pulmonary tuberculosis for India

55. 1. NON-OPERATIVE TREATMENT
a) ATT
b) Traction
• Relieves muscle spasm
• Corrects deformity and subluxation
• Maintains joint space
• Decreases the chance of developing migrating acetabulum
• Close observation
c) Rest
d) Any cold abscess – aspiration + instillation of Streptomycin
+/- INH

56. • Favorable response – CST
• If mild ankylosis present, active assisted movements of hip
should be performed as tolerable
• With traction, patient encouraged to sit and touch forehead to
knee and put the thigh in abduction and external rotation

57. • After 4-6 months,
• Non-weight bearing ambulation permitted with walker/crutches
for first 12 weeks
• Partial weight bearing ambulation for next 12 weeks
• After 12 months from onset of treatment, crutches discarded
• Non-operative treatment – synovial disease, early arthritis and
some cases of advanced arthritis

58. • If response to non-op treatment – Unfavorable, then –
• Synovectomy/Debridement as needed
• Disease under control – ambulation after 3-6 months after
surgery

59. • Advanced arthritis – Gross fibrous ankylosis –
• Non-op treatment to overcome the deformities and assess
movement of hip joint
• Limb immobilized using hip spica for 4-6 months
• Neutral, 5-10° of ER and flexion of 10° in children, 30° for adults
• After 6 months, partial weight bearing in a single spica for 6
months after which support with walker/crutches for 2 years

60. TREATMENT IN CHILDREN
• Traction
• Correction of deformity – rarely plaster application under GA +/-
adductor tenotomy
• Failure to correct deformity – Open arthrotomy, synovectomy
and debridement of the joint
• Arthrodesis/Excisional arthroplasty – delayed till completion of
growth of proximal femur

61. • Gross deformity in child -
• Extra-articular corrective osteotomy is done
• Subtotal excision of contracted fibrous capsule – if some
anatomy of hip joint is retained, + traction, repetitive exercises

62. SURGICAL MANAGEMENT
1. OSTEOTOMY –
• Upper femoral corrective osteotomy – ideal site is as near to the
deformed joint as possible
2. ARTHRODESIS –
• Before ATT – ischiofemoral/iliofemoral arthrodesis
• After ATT – Intracapsular fusion b/w femoral head and acetabulum
• Indication – adult with painful fibrous ankylosis with active/healed
disease

63. 3. EXCISIONAL ARTHROPLASTY
• After completion of growth potential of hip joints
• Provides mobile, painless hip joint with control of infection and
correction of deformity
• Shortening (3.5-5cm) and Instability – can be minimized by post op
traction for 3 months
• Recommended in adults with active/healed disease

65. DISEASE STAGE AND OPERATIVE
PROCEDURE

66. STAGE I & II
• Disease not responding or doubtful diagnosis – ARTHROTOMY
AND SYNOVECTOMY
• II – Synovectomy + removal of loose bodies, debris, loose
articular cartilage and careful curettage of osseous foci should
also be done
• Post op – Triple drug therapy, traction, intermittent active and
assisted exercises for 4-6 weeks, ambulation with walker
support 3-6 months after surgery

67. STAGE III & IV
• Ankylosis of hip joint
• Hip immobilized in slight abduction(10-15°)

68. GUIDELINES FOR INDICATION AND OPERATIONS FOR
TB HIP
Therapeutically refractory or doubtful
diagnosis
Arthrotomy, synovectomy, debridement
Dislocation/subluxation during active stage of
disease
Arthrotomy and repositioning of joint
Juxtaarticular non resolving lesion threatening
the joint
Debridement of the lesion
Unacceptable gross ankylosis of hip in active
stage of disease
Excision arthroplasty
Partial ankylosis with healed disease with
useful range of motion
Juxtaarticular osteotomy to bring the range
of motion to the functional arc
Bony ankylosis of hip in non functioning
position
Juxtaarticular osteotomy to bring the fused
joint to the best functioning position
Painful ankylosis of hip Excisional or replacement arthroplasty

69. HEALED STATUS OF DISEASE
• Upper femoral corrective osteotomy - severe flexion-adduction
deformity
• Upper femoral displacement-cum-corrective osteotomy - fibrous
ankylosis with gross deformity
• Intra-articular or extra-articular arthrodesis – painful ankylosis
• Girdlestone arthroplasty or total joint replacement

71. • In healed TB with subluxation/dislocation of long duration –
• Replacement surgery not advisable
• Stability can be provided by TECTOPLASTY
• It aims to provide an extra-articular weight-bearing surface in
cases of dysplastic acetabulum, hip subluxation or dislocation
with a false acetabulum