MUSCULOSKELETAL TB HIP JOINT FIRM III ORTHOPAEDIC GRANDROUND

MUSCULOSKELETAL TB HIP JOINT FIRM III ORTHOPAEDIC GRANDROUND DR. ONDARI N. J ORTHO II 02 05 2013

Tuberculosis is probably as old as mankind. It's continued presence midst us is a sorry tale of missed oppor tunities and mismanagement by the medical profession Shanmugasundaram T K

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

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

Babcock's triangle

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

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”

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

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

GALLEAZI TEST

Nelaton's line Bryant's triang

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

RADIOLOGY Earliest sign 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

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

TREATMENT Rest Chemotherapy Arthroplasty Arthrodesis Osteotomy

TREATMENT: REST Hugh Owen Thomas urged that TB should be treated by rest – which had to be ‘prolonged, uninterrupted, rigid and enforced’.

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

New WHO Recommended regimen TB disease category Intensive Continuatio phase n phase All forms of PTB and EPTB except TB meningitis and osteoarticular TB 2 RHZE 4 RH TB meningitis, 2 RHZE 10 RH osteoarticular TB

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

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

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

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