May 30, 2024

Tuberculosis of the Hip joint comprises 15% of all osteoarticular tuberculosis which is next to the spine in skeletal tuberculosis.

Potential site for tuberculosis of the Hip joint
Potential site for tuberculosis of the Hip joint

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

It increases intrasynovial exudates

The femur (Flexion, Abduction, and External rotation)

As the capsule thickened by fibrosis: Femur ( Flexion, Adduction, and Internal rotation)

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

Late detection (beyond the stage of exudation and stage of caseous destruction)

Healed by fibrous ankylosis

Fibrous wall cavities:- Encloses lesions that any time can become reactivated

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

StagesClinical FindingsRadiological Features
Stage of SynovitisFlexion, Abduction, External Rotation, Apparent lengtheningSoft tissue swelling, haziness of articular margin, and rarefaction
Stage of Early arthritisFlexion, Adduction, Internal Rotation, Apparent shorterningRarefaction, osteopenia, marginal bony erosion in the femoral head, acetabulum or both
No reduction in joint space
Stage of Advanced arthritisFlexion, Adduction, Internal Rotation, True shorterningRarefaction, osteopenia, marginal bony erosion in the femoral head, acetabulum or both
Reduction in joint space
Stage of Advanced arthritis with subluxation/dislocationFlexion, Adduction, Internal Rotation, True shorterningGross destruction and reduction of joint space, Wandering acetabulum

Classification of the Radiological Appearances

Shanmugasundaram

  1. Normal
  2. Traveling acetabulum
  3. Dislocating
  4. Perthes like
  5. Protrusio-acetabuli
  6. Atrophic
  7. Mortar and pestle appearances

Radiological Appearances

PHEMISTER TRIAD:

Juxtaarticular osteoporosis

Narrowing of joint space

Destruction of femoral head and acetabulum

Management Options

Multidrug therapy

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

  1. Response to non-operative is not favorable
  2. 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

  1. Upper femoral corrective osteotomy to correct severe flexion adduction deformity
  2. Upper femoral displacement-cum-corrective osteotomy
  3. Conversion of painful ankylosis to a sound arthrodesis of the hip
    • Intraarticular
    • Extraarticular
    • Pan-articular
  4. 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