1. TUBERCULOSIS OF HIP

2. TUBERCULOUS ARTHRITIS OF 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. Usual outcome is Fibrous ankylosis
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 osteotomy and 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. Total hip replacement Interpositional (Amniotic Memb.)
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