1. Musculoskeletal tb hip joint FIRM III orthopaedic GRANDROUND dr
Musculoskeletal tb hip joint FIRM III orthopaedic GRANDROUND dr. ondari n . J - ortho ii

4. 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

5. 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

6. 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
The anatomical sites of the lesions could be:
the superior rim of the acetabulam, which is drained by the communicating venous channels of the Batson's prevertebral venous plexus and (b) Babcock's triangle limited by the inferior neck of femur, medially by the epiphysial line or equiva- lent stress lines in adults and laterally by the stress trabeculae of the neck of the femur which is intra- articular in location. Skeletal lesion can occur in the head and neck of femur, in the greater trochan- ter. Rarely, the lesion could be purely synovial in location.

7. Babcock's triangle

8. 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

10. 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”

11. 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

12. The tuberculosis of hip mainly progresses through three stages
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 ) The mnemonics indicate the orientation and appearance of the lower limb during those stages of TB FABER - AL === stands for flexion , abduction , external rotation and apparent lengthening . FADIR - AS === stands for flexion , adduction , internal rotation and apparent shortening . FADIR - TS === stands for flexion , adduction , internal rotation and true shortening.

13. In Stages II and III of the disease, the radiologic features are very obvious and diagnostic, and almost always predict the final clinical outcome

16. The tuberculosis of hip mainly progresses through three stages
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

17. GALLEAZI TEST

19. Nelaton's line
Bryant's triangle

20. 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

21. RADIOLOGY Earliest sign Later 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

25. 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

26. TREATMENT
Rest
Chemotherapy
Arthroplasty
Arthrodesis
Osteotomy

27. TREATMENT: REST
Thomas urged that TB should be treated by rest – which had to be ‘prolonged, uninterrupted, rigid and enforced’.
Treatment
REST
Hugh Owen Thomas long ago urged that tuberculosis
should be treated by rest – which had to be ‘prolonged,
uninterrupted, rigid and enforced’. This often
involved splintage of the joint and traction to overcome
muscle spasm and prevent collapse of the articular
surfaces. With modern chemotherapy this is no
longer mandatory; rest and splintage are varied
according to the needs of the individual patient.
Those who are diagnosed and treated early are kept in
bed only until pain and systemic symptoms subside,
and thereafter are allowed restricted activity until the
joint changes resolve (usually 6 months to a year).
Those with progressive joint destruction may need a
longer period of rest and splintage to prevent ankylosis
in a bad position; however, as soon as symptoms
permit, movements are again encouraged
Hugh Owen Thomas

28. Treatment; Rest Traction Provides rest of the joint
Relieves muscle spasm
Prevents and corrects deformity
Maintains joint space
Minimises chance of developing wandering acetabulum

29. 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, osteoarticular TB
10RH

30. Arthroplasty THR Excision arthroplasty Issues Reactivation of disease
Duration of dz free interval before arthroplasty
Anti-TB use peri-arthroplasty
Excision arthroplasty

32. Arthrodesis Possible option in a young pt with deformed hip
Brittain’s arthrodesis of the hip
Brittain’s arthrodesis of the hip

33. 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

34. THE END