Tuberculosis of the Hip joint comprises 15% of all osteoarticular tuberculosis which is next to the spine in skeletal tuberculosis.
Pathophysiology of TB Hip
Occurs in two different scenarios that are discussed below:
When the infection starts from the epiphysis/ neck of the femur (Intracapsular) exudative process causes diffuse decalcification of the upper end of the femur
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It increases intrasynovial exudates
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The femur (Flexion, Abduction, and External rotation)
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As the capsule thickened by fibrosis: Femur ( Flexion, Adduction, and Internal rotation)
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The destruction spread to the acetabulum, may cause pathological dislocation (thin acetabular roof)
If the infection starts in the pelvis (acetabulum), Joint involvement and symptoms are late
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Late detection (beyond the stage of exudation and stage of caseous destruction)
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Healed by fibrous ankylosis
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Fibrous wall cavities:- Encloses lesions that any time can become reactivated
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Further destruction: Bony ankylosis (Final and complete healing)
Clinical Features
The commonest age of start of illness is the first 3 decades
Pain
- Medial aspect of the knee and maximum towards the end of the day
- Night cries
- With/without sinus
- With/without pathological subluxation/dislocation
Limp is earliest and commonest symptom
Antalgic gait
Tenderness is elicited at the base of Scarpa’s triangle, medial and posterior to greater trochanter on trochanteric pressure
Flexor and adductor spasm
Clinico-Radiological Stages of Tuberculosis of Hip
| Stages | Clinical Findings | Radiological Features |
|---|---|---|
| Stage of Synovitis | Flexion, Abduction, External Rotation, Apparent lengthening | Soft tissue swelling, haziness of articular margin, and rarefaction |
| Stage of Early arthritis | Flexion, Adduction, Internal Rotation, Apparent shorterning | Rarefaction, osteopenia, marginal bony erosion in the femoral head, acetabulum or both No reduction in joint space |
| Stage of Advanced arthritis | Flexion, Adduction, Internal Rotation, True shorterning | Rarefaction, osteopenia, marginal bony erosion in the femoral head, acetabulum or both Reduction in joint space |
| Stage of Advanced arthritis with subluxation/dislocation | Flexion, Adduction, Internal Rotation, True shorterning | Gross destruction and reduction of joint space, Wandering acetabulum |
Classification of the Radiological Appearances
Shanmugasundaram
- Normal
- Traveling acetabulum
- Dislocating
- Perthes like
- Protrusio-acetabuli
- Atrophic
- Mortar and pestle appearances
Radiological Appearances
PHEMISTER TRIAD:
Juxtaarticular osteoporosis
Narrowing of joint space
Destruction of femoral head and acetabulum
Management Options
Traction
- To correct deformity
- To give rest to the patient
In abduction deformity: B/L traction is advised (Because traction of the deformed limb will further increase the deformity)
Advantages:
- Relieves muscle spasm
- Prevents/ corrects deformity and subluxation
- Maintain joint spaces
- Minimize chances of developing migrating acetabulum
- Permits close observation at the hip joint
Palpable cold abscess: Aspirated with installing streptokinase and isoniazid
In favorable clinical response: treatment is continued + movement of hip started (tolerable pain)
Gradually increases to 5-10 minutes every hour (in awake)
Then, after 4-6 months, start ambulation with suitable orthosis and crutches
- Should be non-weight bearing for the first 12 weeks
- Partial weight-bearing for the next 12 weeks
After 12 months: Crutches/ Orthosis may be discarded
Unprotective and weight-bearing are permitted after 18-24 months from the onset of treatment
Non Operative treatment
Early arthritis / Some cases of advanced arthritis
In advanced arthritis:
Usual outcome: Gross fibrosis ankylosis
If ankylosing is anticipated/ accepted:- Limb should be immobilized with plaster hip spica (4-6 months)
Ideal position:
- Neutral (between abduction/ adduction)
- External rotation (5-10 degrees)
- Flexion: 10 degrees in children, 30 degrees in adults)
After 6 months, partial weight-bearing for 6 months with single hip spica, later with the help of orthosis for 2 years
Surgical Options
Indication for surgical procedure
A. In active disease
- Response to non-operative is not favorable
- Outcome is unaccepted
Osteotomy:
- Ankylosing in a bad position
- Upper femoral corrective osteotomy
Arthrodesis
- Indicated in Painful (fibrous) ankylosis with active/healed disease
This procedure should be delayed so as the bone of the hip joint have any growth potential
Excision arthroplasty (Girdlestone excision arthroplasty)
Mobile, painless hip + control of infection and correction of deformity
B. In healed disease
- Upper femoral corrective osteotomy to correct severe flexion adduction deformity
- Upper femoral displacement-cum-corrective osteotomy
- Conversion of painful ankylosis to a sound arthrodesis of the hip
- Intraarticular
- Extraarticular
- Pan-articular
- Conversion of the ankylosing hip to the mobile state by Girdlestone arthroplasty or THR
Summary of treatment of TB Hip according to stages
Synovitis
- Mostly conservative
- ATT
- Traction followed by rest
- Gradual mobilization
- Surgical indication: Only for taking a biopsy
Early arthritis
- ATT
- Traction
- Synovectomy + Joint debridement
Synovial will grow back with new blood vessels (Carries ATT) and disease load is also reduced
Advanced arthritis
- ATT
- Traction
- Arthrolysis
- To improve ROM
- Useful only if limitation due to fibrosis ankylosis
- Remove all pathological and fibrous tissue
- Sub-total synovectomy
- Leave posterior capsule undisturbed to preserve blood supply
- Post operatively: Skeletal traction and ROM as soon as possible
Advanced arthritis with subluxation and dislocation
- Conservative treatment: Traction
- Excision arthroplasty
- Arthrodesis
- Hip replacement
