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Tuberculosis of Hip Joint
Tuberculosis of the hip joint primarily affects the first three decades of life, accounting for 15% of osteoarticular tuberculosis cases. The infection usually originates from a primary focus in the lungs or nearby regions and can lead to various stages of joint involvement, with symptoms including hip pain, limping, and cold abscess formation. Management includes chemotherapy, traction, and potentially surgical interventions, with early treatment significantly improving prognosis.
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This section provides a brief introduction to tuberculosis of the hip joint, highlighting its importance and content overview.
Hip joint tuberculosis is common, especially in the first three decades, constituting 15% of osteoarticular TB cases.
Hip TB originates from a primary focus in the body, with initial symptoms often manifesting late, resulting in severe joint damage.
Symptoms include insidious pain, swelling, limping, and potential referred pain. Important signs include night cries and limp.
Hip TB progresses through four stages: Synovitis, Early Arthritis, Advanced Arthritis, and Advanced Arthritis with Sequel.
Characterized by effusion, specific joint positions causing apparent lengthening, with differential diagnosis considerations.
Untreated, it leads to destructive changes with muscle wasting, cold abscess formation, and noticeable x-ray changes.
Exaggerated clinical signs with significant destruction of joint structures.
Severe destruction leads to joint dislocation, cold abscess burst, and limb length changes.
Radiological progression includes joint space widening in Stage 1 to significant structural destruction in Stage 3.
Different radiological types including coxa magna and protrusion acetabuli, indicating varying levels of joint involvement.
Includes conditions to be differentiated from hip TB such as transient synovitis and rheumatoid arthritis.
Treatment aims include achieving a painless, stable, and mobile joint without deformity or limping.
In early synovitis and arthritis, traction and aspiration therapy are essential for treatment.
In advanced cases, surgical interventions like arthrodesis and positioning are crucial.
Surgical options include synovectomy, debridement, and joint replacement following adequate healing.
Prognosis varies; early treatment shows better outcomes, while advanced arthritis may lead to severe complications.
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Tuberculosis of Hip Joint
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- 2. CONTENT Introduction Pathology Clinical features Stages of TB Hip Radiological features Differential diagnosis Management
- 3. INTRODUCTION Next tospine, hip joint is the most common site for involvement by tuberculosis. Mostly common first 3 decade of life like other osteo – articular disease. It constitute 15 percent of osteoarticular tuberculosis.
- 4. PATHOLOGY Infection ofhip is secondary to some primary focus either in lungs or mediastinal node or iliocaecal region and spread to hip by blood stream. Initial focus may start in acetabular roof > epiphysis ( head ) > Metaphysis or neck ( Babcock triangle ) > greater trochanter . Rarely the disease may start in synovial membrane and may remain as synovitis for months.
- 5. When initialfocus is acetabular roof -- joint involvement is late and severity of symptom is mild – by the time pt. report to hospital extensive destruction already present. TB of greater trochanter may involve the trochanteric bursa without involving the hip for long time. As the upper end of femur is entirely intracapsuler the joint get involve rapidly and disease become osteoarticular Cold abcess in joint – perforate inferior weaker part of capsule rarely acetabular roof – cold abcess can present anywhere around the hip ( femoral triangle , medial ,post and lateral side of thigh ,ischeo – rectal fossa , pelvis )
- 6. CLINICAL FEATURES Insidiousin onset Pain and swelling in the hip and limping are the usual presenting symptoms Sometimes there is referred pain in the knee and is often misleading. Pain is maximum at end of day. Child may wake up from sleep due to pain(night cry) Constitutional symptom like loss of appetite, loss of weight, fever Limp is the earliest and commonest symptom
- 7. During changingof bed patient may support the involved limb with contralateral normal limb. Or pt can “apply traction” on the painful hip on the dorsum of foot by contralateral limb 8 % patient may have palpable cold abscess with or without sinuses . 10% present with pathological subluxation or dislocation Typical antalgic gait
- 8. STAGES OF T.B.HIP Stage 1: Synovitis Stage 2: Early Arthritis Stage 3: Advanced Arthritis Stage 4: Advanced Arthritis with Sequele
- 9. STAGE 1: Synovitis Synovitis with effusion into the cavity. The hip joint assumes the position of maximum capacity –FABER --flexion, abduction and external rotation causing apparent lengthening Pelvic tilt downwards which cause apparent lengthening of affected limb Increased lumbar lordosis Other local signs are warmth, tenderness, muscle spasm and painful limitation of all movements of the joint D/D – traumatic synovitis , rheumatic , non specific transient synovitis , perthes ds , low grade pyogenic infection
- 10. STAGE 2: EarlyArthritis If disease is untreated and the patient is bed-ridden destructive process spreads to the articular surface Limb assumes the position of flexion, adduction (apparent shortening) and internal rotation (FADIR)due to spasm of adductors True shortening not more then 1 cm because ht. of articular cartilage is one cm There is marked muscle wasting of gluteal muscle Cold abscess formation occurs X – ray: localized osteoporosis , decrease in joint space due to decrease in ht of articular cartilage, localized erosion of articular cartilage .
- 11. STAGE 3: AdvancedArthritis Clinical sign of stage 2 is exaggerated Gross destruction of articular cartilage and femoral head and acetabulum
- 13. STAGE 4: Advancedarthritis with subluxation or dislocation With further destruction of capsule and ligaments head of the femur and may shift upwards and dorsally Wandering or migrating acetabulum Dislocation or subluxation may occur Protrusion acetabuli occur Mortar and pestle appearance ( collapse and small femoral head and neck lie in enlarged acetabulum ) Adduction, flexion and internal rotation gets exaggerated There is real shortening of limb Cold abscess bursts and there are sinuses discharging thin pus
- 14. Hip maynot assume the posture of triple deformity of F- AD – IR instead hip may assume F – AB – ER . This may be due to continuous adoption of lateral aspect of thigh of diseased hip resting on bed or due to destruction of iliofemoral ligament If limb has been plastered more than 12 month as in first half of twentieth century growth plate around the knee may get closed – frame knee Coxa magna , coxa valgus , coxa vara
- 15. RADIOLOGICAL FEATURES STAGE1- generalised rarefaction of bones. Joint space appear widened due to effusion STAGE 2- erosion of the articular surface and narrowing of the joint space STAGE 3- destruction of head of femur, dislocation of hip and a break in the shenton’s line
- 16. Radiological type oftuberculosis (acc. to Shanmugasundram) Type 1 – normal Type 2 – migrating acetabulum Type 3 - pathological dislocation Type 4 – perthes disease Type 5 – protrusion acetabula TYPE 6 – atrophic type Type 7 – mortar and pestle appearance
- 23. Hyperemia –large head and neck – coxa magna Thromboembolic phenomena – perthe’s disease Coxa breva due to decrease in blood supply Restriction growth of capital femoral epiphyseal plate and normal trochanteric physis – coxa vara Normal growth of capital femoral epiphyseal plate and Restriction trochanteric physis – coxa valga If joint space is reduced > 3mm – poor prognosis
- 24. DIFFERENTIAL DIAGNOSIS Transientsynovitis Monoarticular rheumatoid arthritis Subacute arthritis Haemorrhagic arthritis Pyogenic arthritis Perthes disease
- 25. MANAGEMENT: Forms of treatment General Chemotherapy Local Role of surgery
- 26. Aim of management Painless Stable Mobile No deformity No limp No limb length discrepency
- 27. Synovitis and earlyarthritis Traction is given to correct deformity and to give rest to the part. Traction relieves muscle spasm and maintains joint space. Any palpable cold abscess should be aspirated with instillation of streptomycin. Active assisted movement should be started as soon as pain subsides After 4-6 months ambulation on suitable caliper or crutches In presence of abduction deformity , for better control of pelvis b/l traction is mandatory otherwise abduction deformity will increase
- 28. Advanced arthritis Theusual outcome is gross fibrous ankylosis. Initial traction regime help to overcome deformity and returns any useful range of motion. Once gross ankylosis is anticipated the limb should be immobilized in hip spica. The ideal position is neutral between abduction and adduction,5-10 degree external rotation,and flexion between 10degree in children to 30 degree in adults
- 29. Role of surgey Synovectomy Debridement Arthrodesis Arthroplasty
- 30. Arthrodesis unsound ankylosiswith healed or active disease deferred till the bone of hip has growth potential extra articular arthrodesis – ischiofemoral or iliofemoral arthrodesis intra articular arthrodesis –with modern anti tubercular drugs , between raw surface of femoral head and acetabulam
- 31. Excision arthroplasty Girdelstone’sexcision arthroplasty – can be done in active and healed stage after the completion of growth potential Provide painless , mobile joint and control of infection and correction of deformity However there is shortening of 3.5 – 5 cm and instability which can be reduced by post op traction( 3 mnths ) . With long term follow up improvement in bone texture and remodelling and false joint formation .
- 32. Joint replacement Aftermaintaining 5 yrs. of healed status After replacement 5 months anti tubercular drugs Still reactivation occurs in 1/3 patients
- 33. PROGNOSIS Early antiTB drugs – good prognosis Early disease ( synovitis and early arthritis ) – good prognosis Advanced arthritis – fibrous ankylosis TB may interfere blood supply of head – same as perthese disease – should be treated like perthes disease with antituberculer coverage