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Tuberculosis TB of the hip is second to spine only hence a good number of cases are visiting the medical facilities every year. Many present in the advanced stage of the disease due to delayed diagnosis. In early stages of TB of hip, there is a diagnostic dilemma when plain X-rays are negative. In the present time, diagnostic modalities have improved from the days when diagnosis was based essentially on clinicoradiological presentation alone.
By the time definite radiological changes appear on plain X-ray, the disease has moderately advanced. The modern diagnostic facilities like ultrasonography USG or magnetic resonance imaging of the hip joint, USG guided aspiration of synovial fluid and obtaining the material for polymerase chain reaction and tissue diagnosis must be utilized. In the treatment, current emphasis is more on mobility with stability at hip. Joint debridement, skeletal traction, and mobilization exercises may give more satisfying results as compared to the immobilization by hip spica.
Adults with advanced arthritis and healed infection should be informed and discussed the various treatment modalities including the joint replacement. More and more surgeons are taking up the challenge of putting the total hip replacement in the active stage of the disease. Until the long term results in active disease are well established, we recommend it for the healed disease only in selected cases.
For example in children, Perthes disease, juvenile rheumatoid arthritis, transient synovitis, bleeding disorders, pyogenic arthritis etc. Similarly in adult's avascular necrosis AVN , degenerative and inflammatory conditions may pose a problem in the diagnosis. Though the diagnosis of TB hip conventionally is still largely based on clinicoradiological findings, however, it is desirable to make a early diagnosis for good results.
How helpful are the modern diagnostic imaging modalities like ultrasonography USG , magnetic resonance imaging MRI , bone scan or immunological and molecular diagnostic tests like polymerase chain reaction PCR to diagnose TB hip at an early stage?
Is it mandatory to subject every patient for tissue diagnosis particularly in the endemic zones for TB, before we start the antitubercular treatment? Even after the diagnosis is made in early stages, what should be our treatment protocol?
When presenting late, there are permanent changes in the joint with varying disability and there is a dilemma of dealing with this morbid anatomical and pathological changes in the joint. Literature has described various treatment options both nonoperative 3 and operative. Total hip replacement THR in the active stage of the disease is yet another area of controversy.
We have discussed some of these issues on the basis of available knowledge on the subject. We suggest that treatment options offered to the patients should depend on the stage of involvement and must be discussed thoroughly with the patient, despite the stage of involvement before decision is taken. Osteoarticular TB is secondary to primary pathology in lungs, lymph nodes or any of the viscera. Through the hematogenous route, the bacteria reach either to synovium or bone.
When it lodges first in synovium, the synovial membrane becomes swollen and congested. The granulation tissue from the synovium extends over the bone resulting in necrosis of sub chondral bone, sequetra and may be kissing lesion on either side of joint. It may start as extra articular or juxta articular lesion. When the disease starts as intraarticular, it progresses fast to involve the whole joint.
An extra articular lesion can also progress further to involve the joint. Cold abscess that usually forms within the joint may perforate the capsule to present around the hip joint in the femoral triangle, medial, lateral or posterior aspects of thigh, ischio rectal fossa. Disease usually starts during first three decades but no age is immune. Pain in the hip, limp, restriction of movements is present in almost all the cases. Depending upon the extent of involvement there can be deformity, shortening of the limb, swelling, pathological dislocations, and sinuses.
In the stage of synovitis, there is effusion in the joint and the affected limb is flexed, abducted, and externally rotated with an apparent lengthening of the extremity. There is a restriction essentially of terminal range of movements. In the stage of early arthritis, with progressive destruction of the joint, the limb goes into flexion, adduction, and internal rotation, with an apparent limb shortening.
In the active stage, there is muscle spasm, every attempted movement of the hip can be painful, and child walks with an antalgic gait. The joint space is still maintained in this stage. In the stage of advanced arthritis the destruction leads to irregular and hazy joint margins with diminished joint space [ Figure 2 ]. The hip movements are painful and grossly restricted with shortening of the limb. The attitude of the limb and deformity does not always correspond with the stage of arthritis.
The hip is subluxated posteriorly and superiorly with true shortening of the involved limb. Babhulkar and Pande 9 introduced a classification, based on above clinicoradiological presentations into stage of synovitis, early arthritis, stage of arthritis and stage of advanced arthritis. The presence of apparent shortening or true shortening separated early arthritis and arthritis [ Table 1 ]. Tuli 1 suggested modification in this classification [ Table 2 ].
Irregular and hazy joint margins with diminished joint space on left side. It is suggested that in the endemic regions for TB, a clinical diagnosis supported by radiographs is adequate for starting the treatment. In the stage of synovitis, there may not be changes in the joint and many a time's diagnosis is missed; hence confirmation of diagnosis by demonstration of tubercular bacilli or histological features in biopsy is recommended.
In advance stages of arthritis, radiological changes are typical and tissue diagnosis may not be required. Some other hip conditions presenting with pain and limp are transient synovitis of the hip, Legg—Calve—Perthes disease, osteomyelitis of the upper end of the femur, injury hip, acute infective arthritis of infancy and childhood, osteoid osteoma of the neck of the femur with synovial involvement, villonodular synovitis, rheumatoid arthritis, AVN of the head of the femur, giant cell variants of upper femur, etc.
In the stage of synovitis in TB of hip, plain X-rays do not show any findings or at the most only soft tissue swelling is visible. With further progression of the disease, periarticular osteoporosis, hazy, and irregular joint margins with reduction in the joint space is seen.
Campbell and Hoffman 16 suggested that there is a relationship between various radiological types and the functional outcome. In the present time MRI has helped us to detect the early morbid pathology in the joint as it shows the predestructive lesion like edema and inflammation.
It is a sensitive test to detect soft tissue abnormalities in and around the joint. MRI is not specific for TB of hip. The tissue diagnosis may be indicated in such instances. The tissue obtained from the diseased site must be subjected to histology, AFB staining PCR and also for culture and sensitivity. Singhal et al. It is an important useful investigative adjunct to correlate and confirm the diagnosis after clinical and synovial fluid evaluation.
Synovial biopsy may give conclusive diagnosis where clinical diagnosis is equivocal. Early diagnosis and effective chemotherapy are vital to save the joint. In addition to medical treatment, traction preferably skeletal is recommended to all patients. In the case of the abduction deformity, traction on the other limb is also applied to stabilize the pelvis. Traction relieves the muscle spasm, prevents or corrects deformity and subluxation, maintains the joint space, minimizes the chances of development of migration of acetabulum and permits close observation of the hip region.
Another advantage with traction is that it keeps the joint surfaces apart; hence with an early start of mobilization exercises of the hip, functional range of movements can be achieved. With late presentation, the deformities may become permanent. The TB heals with fibrosis, hence may not respond to traction.
Unlike pyogenic infections, proteolytic enzymes are not produced in tubercular infection; articular cartilage survives for a long time thus preserving mobility in many patients. Tuli 8 earlier was recommending partial weight-bearing only after months of treatment, and full weight-bearing only at 18 months. However, in the present day scenario, we recommend weight-bearing earlier, whenever patient can tolerate the pain.
Moon et al. To establish the diagnosis the patient should be subjected to USG examination; synovial effusion can be aspirated and subjected for cytology, AFB smear and PCR examination. If necessary, biopsy can be taken from diseased tissue to establish the diagnosis. The prognosis after chemotherapy, traction, rest and mobilization exercises is very good in this stage and the surgical interventions usually are not required.
MRI may show synovial effusion, osseous edema and areas of bone destruction. In addition to traction and chemotherapy, analgesics supplementation is necessary till spasm of the muscles is relieved. Nonweight bearing range of motion exercises are started whenever patient is able to co-operate. A vigorous passive exercise may produce further pain and spasm and should be avoided. Failure to respond in the form of improvement in constitutional features, reduction of pain around hip, increase in the range of movements to nonoperative treatment may call for confirmation of diagnosis.
Synovectomy and joint debridement are done with an aim to reduce the disease tissue load and ascertain diagnosis. Vora 23 cautioned that during synovectomy, utmost attention should be given to safeguard the feeding vessels to the head, located beneath the hypertrophied synovium. He also suggested that femoral head should not be dislocated to facilitate the synovectomy procedure. The prognosis in general is good. Deformities are correctable, shortening is minimal and range of movements can be more than functional depending upon how seriously exercises regimen is followed.
The clinicoradiological presentation is typical of tubercular arthritis in this stage. Irregular and hazy joint margins, destruction of bone on either side of joint, erosions and reduced joint space are classical plain X-ray findings. There is gross destruction of capsule, synovium, bones and articular cartilage. Shortening of limb and deformity further complicates the condition. In addition to the treatment as advocated above, arthrolysis of joint with joint debridement can be very helpful. The end result after the procedure is usually a healed disease with shortening of limb and moderate to gross restriction of movements.
Arthrolysis aims to achieve the useful range of movements in the cases with gross limitation of movements not responding to traction and exercises. For example, it may not help in wandering acetabulum type or pathological dislocation or even in pestle and mortal appearance. All pathological and fibrous tissues are excised carefully without compromising with vascularity of remaining part of the upper end of the femur.
It is wise to leave the posterior capsule undisturbed because it carries vital blood supply to the femoral head. Posterior capsule is generally not shortened as most of the patients have flexion deformity. Before the completion of the operative procedure, ensure that adequate range has been achieved by passive movements while under anesthesia.
After surgery, skeletal traction is applied, and movements of the hip are allowed under supervision as soon as patient is able to do.
As expected, gross destructive changes in the joint will not allow for even functional range of movements.
Tuberculosis of hip: A current concept review
Metrics details. Osteoarticular tuberculosis is rare in Germany. In particular, trochanteric bursitis is an extremely rare manifestation of osteoarticular tuberculosis. We describe a case of tuberculous coxitis with trochanteric bursitis, successfully treated with a fourfold tuberculostatic therapy. We report the case of a year-old human immunodeficiency virus-negative Sudanese man with osteoarticular tuberculosis, who was originally admitted with the suspected diagnosis of ankylosing spondylitis. Low grade fever together with the positive result of an interferon-gamma release assay test as well as findings from magnetic resonance imaging provided clues to the diagnosis. A definitive diagnosis could be set after a computed tomography-guided biopsy.
Although the prevalence of tuberculosis reduces, it still belongs to the most important infectious diseases worldwide even in industrial countries. We report an unusual case of tuberculous coxitis in a year-old healthy native female with recurrent hip pain. While X-ray and microbiological examination of the aspirate showed no abnormality, only extended diagnostic measurements and detailed history led to the diagnosis of TBC. Although the patient did not show any pulmonary symptoms open tuberculosis was confirmed.