Transcript Tuberculosis of Hip joint

TUBERCULOSIS OF HIP
TUBERCULOUS ARTHRITIS
OF HIP
Clinical Presentation
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Common during first 3 decades of life
General – As in any tuberculosis infection
Systemic- Depending on primary focus
Local
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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
Staging
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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
Staging
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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 (2550%)
X-ray - Erosion of articular margin
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Reduced joint space
Adjacent osteoporosis
Staging
Stage III (Advanced arthritis)
Deformity, destruction & shortening as
in II but more marked
Movement loss > 75%
o Capsule is destroyed,thickened and
contracted.
 X-ray – Accentuated findings than II
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Staging
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Stage IV (of complications/ of real
shortening)
Wandering acetabulum
Protrusio acetabuli
Mortar & pestle appearance
Frank post. dislocation of hip
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Clinical & Radiological finding
Destruction ileofemoral ligament or postural
prolonged external rotation attitude
Shenton’s line broken.
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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.
Other Complication
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Soft tissue complications
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Abscesses
Sinuses
Bony complication
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Coxa Magna
 Growing stage hyperemia
 Coxa valga with increased anteversion of neck
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Acctabular dysplasia
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Frame Knee
 POP for > 12 Mths.
 Premature fusion of growth plates leads to marked
shortening and limitation of movements.
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Coxavera – fragmentation and flattening of femoral head
(Perthe’s type)
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
Management
Investigations
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General –
Specific
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Hb%,TLC,DLC,ESR,PPD
Radiological
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X-ray/ Sinogram
Ultrasound
CT Scan/ MRI
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Serological – ELISA, PCR
Bacteriological
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Synovial fluid
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AFB staining/ Culture & Sensitivity
Histopathology/ Aspirate examination
Polymorpho Leukocytosis (10-20,000)
Decrease sugar
Increase protein
Poor mucin clot
Guinae pig innoculation
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
Treatment
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Mechanical support
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Splints & Plasters
Traction ( at times bilateral)
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To relieve spasm
Correct the deformity
Joint surfaces apart
Physiotherapy with traction on
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
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In Advance arthritis
Usual outcome is Fibrous ankylosis
Immobilize in ideal position in POP spica for 6
months
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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.
Special considerations in
children
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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.
Surgical intervention
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Adjuvant to ATT (response to conservative
treatment
unfavourable
or
outcome
unacceptable)
Synovectomy & joint debridement
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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.
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 deformityiliofemoral extraarticular arthrodesis easy to perform.
Best position 30 degree flexion.np adduction or abduction,5-10
degree of external rotation .
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Abbott-lucas technique of fusion of hip
joint in two stages
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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)
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.
Arthroplasty
Girdle stone (excisional)
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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.
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Interpositional (Amniotic Memb.)
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Total hip replacement
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Atleast after 10 years of last evidence of active
infection.
Reactivation recorded in 10-30% of cases.
Treatment of complication
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Sinuses
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Heal by ATT in 2-3 months
If not, excision of tract
Abscesses
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Aspiration & streptomycin/ INH injection
Evacuation
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