MUSCULOSKELETAL TB
HIP JOINT
FIRM III ORTHOPAEDIC GRANDROUND
DR. ONDARI N . J - ORTHO II
02-05-2013
Tuberculosis is probably as old as
mankind.
It's continued presence midst us is a
sorry tale of missed opportunities and
mismanagement by the medical
profession
Shanmugasundaram T K
Epidemiology cont.

Bones and joints and affected in ~5% of pts
with TB

Commonest is spinal TB in ~50% of cases

Hip – 15% of all osteoarticular TB


Can occur in any age group but is more common
in children.
Next common after spinal TB
PATHOLOGY/ PATHOGENESIS: HIP JOINT




M.TB entry – inhalation, ingestion, skin innoculation
Primary complex, secondary spread and tertiary lesion
Always starts in bone, rarely synovium –granulomatous
reaction
The anatomical sites of the lesions:
1.The superior rim of the acetabulam
 2. Epiphysis
 3. Babcock's triangle
 4. Greater trochanter.
 5. Rarely, purely synovial in location.


In hip joint head and neck are intracapsular so a bony
lesion invades the joint early
Babcock's triangle
PATHOGENESIS cont.

If synovium is involved – marked effusion

Articular cartilage slowly destroyed



At synovial reflections there’s active bone
erosion – increased vascularity
Secondary infection by pyogenic orgs common
If articular cartilage severely destroyed healing
is by fibrous ankylosis
CLINICAL FEATURES

h/o previous TB infection or contact

Insidious onset, chronic course

Most pts are children

Prior constitutional symptoms

First symptom stiffness of hip with a limp

Pain may be absent in early stages

Pain worse at night – “night cries”
EXAMINATION



Look

Gait - stiff hip gait, antalgic, trendelenburg

Muscle wasting

Swelling due to cold abscess, Discharging sinuses

Flexion deformity, Limb length
Feel

Skin temperaturess, any swelling

Tenderness

Assess any pelvic tilt
Move


All mvts usually restricted due to pain and muscle spasm
Special tests

Thomas test

Bryant’s triangle/ Nelaton’s line

Galleazi’s test

Gauvain’s sign
The tuberculosis of hip mainly
progresses through three stages .
a- stage of synovitis ( FABER - AL )
b- stage of arthritis ( FADIR - AS )
c- stage of erosion ( FADIR - TS
GALLEAZI TEST
Nelaton's line
Bryant's triangle
INVESTIGATION




Haemogram –relative lymphocytosis
ESR
Mantoux test
Synovial fluid aspiration
AAFB 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% of pts
 Histology

Granulomatous inflammation/ caseous necrosis
 Melon seed bodies

RADIOLOGY

Earliest sign
A
general haziness of the bones
 Normal joint space
 An area of rarefaction in the babcock’s triangle
 Increased joint space

Later
 Lytic
lesions with no or minimal reactive sclerosis
 Travelling or wandering acetabulum
 Posterior dislocation of the hip
 Motor and pestle appearance
 Protrusio acetabulare
 Fibrous ankylosis
Note

A triad of radiologic abnormalities (Phemister triad);
 periarticular
osteoporosis
 peripherally located osseous erosion
 gradual diminution of joint space suggests the dx of TB

Occasionally, wedge-shaped areas of necrosis
(kissing sequestra) in joint margin. These marginal
erosions may simulate RA
TREATMENT

Rest

Chemotherapy

Arthroplasty

Arthrodesis

Osteotomy
TREATMENT: REST

Hugh Owen Thomas
Thomas urged that TB should
be treated by rest – which
had to be ‘prolonged,
uninterrupted, rigid and
enforced’.
Treatment; Rest

Traction
 Provides
rest of the joint
 Relieves muscle spasm
 Prevents and corrects deformity
 Maintains joint space
 Minimises chance of developing wandering
acetabulum
New WHO Recommended regimen
TB disease category
Intensive
phase
Continuation
phase
All forms of PTB and EPTB except TB
meningitis and osteoarticular TB
2RHZE
4RH
TB meningitis,
2RHZE
10RH
osteoarticular TB
Arthroplasty

THR
 Issues
 Reactivation
of disease
 Duration of dz free interval before arthroplasty
 Anti-TB use peri-arthroplasty

Excision arthroplasty
Arthrodesis


Possible option in a young pt with
deformed hip
Brittain’s arthrodesis of the hip
References

Campbells operative orthopaedics

Appleys system of orthopaedics and fractures

2009 TB guidelines by ministry of health

ROBERT JOHNSON, K. L. BARNES, R. OWEN Froni REACTIVATION OF TUBERCULOSIS AFTER
TOTAL HIP REPLACEMENT

Qiaojie Wang, MD; Hao Shen, MD; Yao Jiang, MD; Qi Wang, MD; Yunsu Chen, MD; Junjie Shao,
MD; Xianlong Zhang, MD CEMENTLESS tha IN ADVANCED TUBRCULOSISI OF THE HIP
THE END