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TUBERCULOSIS OF HIP

TUBERCULOSIS OF HIP. TUBERCULOUS ARTHRITIS OF HIP. 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

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TUBERCULOSIS OF HIP

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  1. TUBERCULOSIS OF HIP

  2. TUBERCULOUS ARTHRITISOF HIP

  3. 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

  4. 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

  5. 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

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

  7. 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 • Shenton’s line broken.

  8. 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.

  9. 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 > 12 Mths. • Premature fusion of growth plates leads to marked shortening and limitation of movements. • Coxavera – fragmentation and flattening of femoral head (Perthe’s type)

  10. 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

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

  12. 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

  13. 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

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

  15. 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

  16. 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.

  17. 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.

  18. 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.

  19. 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 >18 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 .

  20. 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)

  21. Brittain’s 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 osteotomyand a slot in the ischium.

  22. 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.

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

  24. Treatment of complication • Sinuses • Heal by ATT in 2-3 months • If not, excision of tract • Abscesses • Aspiration & streptomycin/ INH injection • Evacuation

  25. Thank You

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