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

oppor tunities and mismanagement by the

medical professionShanmugasundaram 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

Within fibrocaseous mass mycobacteria may remain with potential of flare many years later

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

Thomas urged that TB should be treated by rest – which had to be ‘prolonged, uninterrupted, rigid and enforced’.

Hugh Owen Thomas

Treatment; Rest

Traction

Provides rest of the joint Relieves muscle spasm Prevents and corrects deformity Maintains joint space Minimises chance of developing wandering acetabulum

TB disease category

Intensive phase

Continuation phase

All forms of PTB and EPTB except TB meningitis and osteoarticular TB

2RHZE 4RH

TB meningitis,

osteoarticular TB

2RHZE 10RH

New WHO Recommended regimen

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