Tuberculosis of hip

by Naveen

Contents
History
Predisposing factors Pathology Clinical features Investigations Management

 Tuberculosis is a world wide problem, nearly

30 million peoples are suffering from TB. Among these, 3 million are dying every year. Major problem in developing countries (Nigeria, India, south east Asia & Korea) India having about 1/5th of world TB population. Nearly 1-3 % pts having skeletal involvement

Predisposing factors
Disease of low socio-economic group Malnutrition Poor sanitation Living in crowding areas Immunodeficiency (Exanthematous fever, multiple pregnancies, alcohol abuse, IV drug abuse, HIV, old age) Repeated trivial trauma (bone oedema / heamatoma)

Organism, Spread
M.C organism - M. tuberculosis (acid fast). Atypical bacteria (M. bovis, M. kansassi, M. marinum, M. avium-intracellular complex, M. scrofulacium.) rarely cause skeletal lesions Source infected person with actively multiplying bacilli Route man to man by drop lets

Fr om Wor l Book 2001 Wor ld Book, Inc ., 233 N M d . ichigan Avenue, Sui te 2000, C hicago, IL 60601. All r i ghts reser ved. Gr apes/Mc haud/Science Sourc e fr om P i hoto Researc her s

 Skeletal involvement through haematogenous route and always from primary focus (lungs, LN, mesentery)

Bone & joint involvement -2-3 yrs after primary focus. The predilection of skeletal TB
Spine Hip Knee S.I joint Elbow Foot (Metatarsals & Phalanges) Ankle Tarsal bones (Calcaneum) Metacarpals & Phalanges Greater trochanter bursa & then Wrist.

Bursal sheaths & tendon sheaths also involved. Mandible & TMJ are least commonly involved.

Anatomy of hip joint

Hip (ball & socket) joint consisting of - Acetabulum (extra capsular) - Head & neck of femur (intra capsular) Movements Flexion 115o Extension 15 -20o. Abduction 45o Adduction 30o. Internal rotation 45o External rotation 45o Anteriorly femoral A, N & V Posteriorly sciatic nerves

Tuberculosis of hip joint

Hip is second M.C site for TB involvement (after spine) Spine : hip 10 : 7 Accounts 15% of all osteo-articular tuberculosis Children are common victims

Common sites
Roof of acetabulum Femoral epiphysis Metaphysis Greater trochanter Synovial membrane (rare) Trochanteric bursae

Clinical features
Common -1st 3 decades of life M.C & earliest symptom is painful limp Antalgic gait (short stance phase) Night cries in case arthritic stage 8% cases with cold abscess + scars & sinuses 10% cases with pathological posterior dislocation Long duration course

Clinical features Cont

Tenderness over joint line Deformity Flex-Abd-ER / Flex-Add-IR Muscle wasting (gluteal, thigh) Constitutional symptoms - Fever - Malaise - Loss of appetite - Evening rise of temperature - Loss of weight

H/o pulmonary TB

pathology
Reticulo endothelial cells deposited in the skeletal tissue. Characterized by accumulation of polynuclear cells. Causing rapidly replaced by monocytes & macrophage TB bacilli are phagocytosed and broken down Their lipids are dispersed through out the cytoplasm of mononuclear cells to form epitheloid cell.

 Epitheloid cells have vesicular nucleus, abundant cytoplasm,

indistinct margins. Forms large epitheloid reticulum. Large langhans giant cells are formed by fusion of number of epiteloid cells Form caseation necrosis to remove the necrotic tissue. The mass formation by the reactive cells of RE cells consists of nodules called as tubercle. Tubercles grows by expansion and coalescence. The caseation material softens and liquefy. Caseation necrosis is the diagnostic of TB pathology.

Cold abscess
Liquefaction of caseous material + reactive exudative + serum & leukocytes Tracts along fascial planes or NV structures Common sites a. Inguinal region b. Medial side of thigh c. Femoral triangle d. Gluteal region e e. Lateral aspect of thigh other ischio-rectal fossa / intra-pelvic abscess.

Stages of TB
Stage of onset (1 month - 1 year) A. Synovitis Stage of destruction (1 3 year) B. Early arthritis. C. Advanced arthritis. D. Advanced arthritis with subluxation / dislocation E. Terminal (after moth) arthritis Stage of repair & ankylosis (2 3 year)

Synovitis
One month to 1 yr Due to juxtra-articular osseous lesion causing irritable hip Flexion - abduction external rotation (FABER) causing apparent lengthening (no true or real shortening) Only extreme (terminal) degrees of movement are limited & painful. X-ray shows - widening joint space - soft tissue swelling with / without rarefaction of bone.

Synovitis

cont...

D/D: 1. Traumatic synovitis, 2. Rheumatic / rheumatoid arthritis, 3. Non-specific transient synovitis, 4. Low grade pyogenic infection, 5. Perthes disease, 6. Slipped capital femoral epiphysis, 7. Juxtra-articular disease causing irritation of joint, 8. Ilio-psoas spasm due to abscess in its sheath or overlying LN or viscera

Synovitis

cont...

If any doubt about diagnosis, repeat radiological & other non-invasive investigations at 3 -6 wks. USG shows swelling of soft tissue of hip joint. MRI shows synovial effusion, oedema of bone & soft tissue. Biopsy rarely required.

Early arthritis
* Localized erosion & destruction of AC. * Attitude of limb in Flex-Add - IR - apparent shortening; * True / real shortening not more than 1 cm. * Night cries may be present * Muscle wasting * Restriction of movement in all directions. * X-ray - localized osteoporosis, - slight narrowing of joint space * MRI - synovial effusion - small area of bone destruction & bone oedema.

Advanced arthritis:
* Attitude of limb Flex-Add-IR are aggravated. * Further restriction of movement & more muscle spam & capsular contracture. * Diffuse muscle wasting * Exaggerated true & apparent shortening. * Gross destruction of articular cartilage, femoral head, and acetabulum. * Capsule is further destroyed, thickened & contracted.

Advanced arthritis with subluxation / dislocation

* Further destruction of acetabulum, femoral head, capsule & ligaments.
* Upper end of femur may be displaced upwards & dorsally (lower part of acetabulum is empty) wandering / migrating acetabulum. Shentons line is broken. Rarely frank pathological posterior dislocation due to severe destruction of capsule & acetabulum. (it is rare in children). * In some cases, femoral neck & head grossly destroyed, collapsed and small which is present in enlarged acetabulum Mortar-Pestle appearance. * Movements are grossly restricted except in some cases like wandering acetabulum, Mortar-Pestle picture & protrusio-acetabulum may retain good movements for long time (flexion affects lastly). * In some cases disease healed in displaced position, the femoral head supported by buttress formed over its posterio-superior aspect.

Cases of atypical presentation

* Clinical features are not typical * Atypical deformity (ct FABER / FADIR) in relation to X-ray findings. - Partially treated case - Pt is ambulatory (postural changes) - Damage of ligaments & capsule - Severe damage & absorption of head & neck

Diagnosis

Diagnosis
* Strictly speaking tuberculosis diagnosed by identification of TB bacilli, but is not possible in all cases because Acid fast bacilli rarely seen - Synovial fluid aspirate - 10% case - Synovial tissue - 20% - Regional LN - 30% - Osseous cavities / destroyed areas - 10% * So diagnosis is made based on combined clinical, laboratory, radiological findings

Diagnosis cont ,
Clinically * Skeletal TB mostly occur during first 3 decades of life * Insidious onset, mono articular / mono-osseous involvement * Constitutional symptoms - low grade fever, lassitude (afternoon), anorexia loss of Wt, night sweats, tachycardia & anaemia * Local signs & symptoms pain, night cries, painful limitation of movements, muscle wasting & regional lymphadenopathy. * During acute stage, protective muscle spasm is severe, holding the hip in flexion. Joint is warm, swollen & tender * Cold abscess & sinuses multiple with undermined edges with serosanguineous discharge * Aspirate of joint fluid showing yellowish white flakes

Blood test
* Relative lymphocytosis, * Low Hb, * Raised ESR are found in active disease (ESR is only has prognostic value on repeated estimation)

Tuberculin skin Testing

1. Mantoux 2. Heaf test (Tine test)

Mantoux
* Inject 0.1 ml of TU PPD Read reaction at 48-72 hours
Measure only induration in mm

* Tuberculin Wheal 10 mm in diameter

1. Mantoux test

cont

Negative test even with active disease seen when ass with - Miliary TB, - TB meningitis, - During high fever - Certain exanthemata, - After viral vaccination, - Recent viral infection, - Steroid therapy, - Severe malnutrition - HIV

2. Heaf test (Tine test)

Multiple puncture test. * By using Heaf guns with six needles * Undiluted tuberculin spread over the skin * Test read after 3 days * Positive reaction is indicated by at least 4 distinct indurated papules
In Mantoux test, Diluted tuberculin (PPD); where as in Heaf / Tine test, Undiluted tuberculin is used.

Roentgenogram
Bony changes (X-ray) seen 2- 4 mon. after the onset of disease Synovitis & early arthritis * Localized osteoporosis is first radiological sign * Soft tissue shadows due synovial fluid, thickened synovium, capsule & peri-capsular soft tissue swelling * Articular margins & bony cortices become hazy (washed out appearance)

Roentgenogram
In advanced stage

cont

* Areas of trabecular or bony destruction (osteolysis)

* Bony collapse, subluxation /dislocation & deformity of joint

* The growth plate may be destroyed causing irregular growth or premature fusion.
In center of trabecular cavity, there may be

sequestrum of cancellous bone or

 calcified bony tissue giving appearance of irregular soft, feathery cock like sequestrum in cavity.
There is no sub-periosteal reaction, but is seen if

secondary infection occurs or there is sinus formation (pyogenic synovitis new bone formation)

Presence of irregular calcified plaques in the walls of chronic abscess or sinus is characteristic of TB infection of long standing

Roentgenogram

cont

Stage of healing * There is remineralization & reappearance of bony trabeculae and sharpening of cortical & articular margins

Early arthritis of hip

Bone is rarefied
Cartilage (joint) space is maintained

A
Slight diminution of joint space Juxtra articular lytic lesion in acetabulum B

Stage of arthritis

Localized osteoporosis Break in Shenton's arc

Widened acetabulum
Mild coxavara Protrusio acetabulum AVN of capital femoral epiphysis (Perthe's type)

Severe arthritis of Lt hip (IV)

Shentons line broken Emptying of lower half of acetabulum

Grossly destroyed femoral head & neck

Wandering acetabulum Mortar pestle appearance

Advanced arthritis
Cartilage is destroyed
Articular surfaces of acetabulum & femoral head have lost their sharp definition Complete joint destruction of joint

Protrusio acetabulum

Types of diseases
1. the caseous exudative type. comm. seen in children. on set is less insidious. more exudative formation. more distruction. sinus formation is more common.

 2.the granulatig type.

Seen in adults. insedious on set. no sinus. abscess formation is rare. example caries sicca.

Shanmugasundaram classification (Radiological)

Normal appearance
Traveling acetabulum Dislocated hip Perthes type Protrusio acetabulum Atrophic type Mortar-Pestle appearance

Prognosis
* Joint space reduced to 3 mm or less poor prognosis.
* Good results seen in - 92% of normal hip; - 80% of Perthes picture; - 50% of dislocated hip; - 29% in traveling acetabulum / Mortar-Pestle type.

CT scan
* Can detect small lytic areas & marginal erosions (not seen on X-ray) Sequestrum in cavities
* Soft tissue swelling (Oedema, granulations, exudations & abscess formation) also detected much earlier * CT guided biopsy is effective method of obtaining tissue for HPE Changes are non- specific (similar changes seen in trauma, Pyogenic infection and neoplasm)

MRI
* Confirm the CT & X-ray findings, but also detect inflammation & oedema in active disease which is more extensive than radiological destruction in bone.
* Once radiological changes are established no over advantage with MRI / Isotope scan.

 Pre-destructive phase is visualized by MRI or by bone scan, but not CT & X-ray Like X-rays, CT & MRI 3 - 6 months after the onset of treatment may show deterioration of pathological process, so no need of unnecessary alarm. * Signs of improvement seen at 6months - Remineralization; - Reduction of eroded area & cavities; - Reduction of peri articular soft tissue shadows; - Resolution of fibrotic mass / abscess; * Deterioration of clinical, laboratory & imaging features 6 months after chemotherapy warrants biopsy to ascertain diagnosis

USG

* It is ideal for TB synovitis (degree of extent of tendon & tendon sheath). * Also shows large / medium sized Psoas abscess.
(Soft tissue swelling / abscess can easily appreciated by CT / MRI).

Synovial fluid examination

* Marginally helpful in early cases. Shows leukocytosis with predominant PMN cell
* Glucose content markedly reduced. * Protein levels are elevated with poor mucin clot

* Synovial joint aspirate is an excellent material for PCR for TB

Guinea pig inoculation

* Pus / joint aspirate / liquefied granulation tissue / curette material from the sinus / ulcer may be injected in to peritoneum of guinea pig tubercles formation in peritoneum in 5- 8 wks indicates positive

This test is un-economical, but most reliable proof of tuberculous pathology

Isotope scintigraphy
* It is uncommon diagnostic technique. * Currently used isotopes 99Tc, 67Ga &111In

* 99Tc scintigraphy is extremely sensitive, but lack of specificity (99Tc scan may shows increased uptake in osteoporotic fracture, infection, stress fracture & healing traumatic fracture & inflammation due to degenerative OA or malignancy) so it is not diagnostic.

Serological investigations
A. ELISA

for antibody to mycobacterial antigen-6, demonstrates at cut of 1: 32. Sensitivity 94%; specificity 100% in bone & joint TB

B. PCR has 40% sensitivity; 100% specificity * Synovial aspirate is excellent material for PCR

Serology is also useful in D/D of Brucellosis, typhoid & syphilitic infection

Biopsy
*

It is mandatory in doubtful cases, particularly in early stages.

* Collection granulation, synovium, bone & lymph node During open biopsy, synovectomy /curettage done as part of therapeutic measures

* Bone & joint granulomatous lesions in order of frequency D/D - TB Mycotic infection Brucellosis Sarcoidosis T. leprosy
* Histopathology distinguish between infection & malignancy; on the other hand between suppurative & granulomatous conditions

Management

Prophylaxis
* BCG .0 -86% protection * INH - 5 mg / kg INH, at least 6 months. - Some suggests Rifamycin 10 mg /kg along with INH for first 3 months

General principles of management

* Assessment of joint damage

* Aim is elimination of infection - provision of painless mobile (function ROM) stable joint
* Rest to the joint with traction / brace * ATT

* Improvement of general condition

* Abscess drainage (if present)

* Sinus excision (If present)

ATT
First line drugs (Standard): High efficacy & low toxicity Bactericidal: 1. INH (H) 5 mg /kg 2. Rifampicin (R) ..10 mg /kg 3. Pyrazenamide (Z) 25 mg /kg 4. Streptomycin (S)...15 mg /kg Bacteriostatic: 1. Ethambutol (E).15 mg /kg

 Second line (Reserved) drugs: Low efficacy & relatively high toxicity Old drugs 1. Thioacetazone 2. PAS 3. Ethionamide 4. Cycloserine 5. Kenamycin 6. Amikacin 7. Capreomycin Newer drugs 1.Ciprofloxacin 2. Ofloxacin 3. Clarithromycin 4. Azithromycin 5. Rifabutin

Bactericidal: Capreomycin (A), Kanamycin (K), Fluoroquinolones.

Bacteriostatic: Ethionamide (Et), Cycloserine(C) PAS.

* INH Rapidly multiplying bacilli (Intra- Extra cellular) * Rifamycin -casseous material * SM - rapidly multiplying bacilli (Extra cellular) * Pyrazenamide -Slow growing bacilli (intra-cellularly & at inflamed areas * Ethambutol Prevent resistance to other drugs * Single drug never be used (except prophylaxis)

Categories
Category-I
* New cases of severe form of extra-pulmonary TB incl. skeletal TB

Category-II
* Treatment failure (again positive after 5 months after treatment) * Relapse (re-positive after declaring cure) * Treatment after interruption (of 2 months)

Category-III
* Less severe forms of extra-PTB (LN, Bone [excluding spine] joint & skin]. In this case bacillary load is small

Category-I
* New cases of severe form of extra-pulmonary TB incl. skeletal TB

2 H3R3Z3E3 4 H3R3 (RNTCP-1997) 2 HRZ with S or E 4 HR or T. (WHO-1997) Current resume 2 HRZE3 & 4HR FOR DEFAULTERS ,RELAPSES 3HRZES3 & 1HRZE &5HRE

Category-II
* Treatment after interruption (of 2 months) * Treatment failure (again positive after 5 months after treatment) * Relapse (re-positive after declaring cure)
2 H3R3Z3E3S3 + 1H3R3Z3E3 5 H3R3E3 (RNTCP-1997) 2 HRZES + 1HRZE 5 HRE or 5 H3R3E3 (Weakly thrice)

Category-III
Less severe forms of extra-PTB (LN, Bone [excluding spine, joint & skin]. In this case bacillary load is small 2 HRZ 4 HR or 4 H3R3 or 6 HE

Rifampicin : liver damage,bowel upset,rashes,pink staining of urine sweat $ saliva. Isoniazid : liver damage, neurotoixity. Rearly retro bulbar neuritis,convelsions. Pyrazinamide:

Metallic taste, Photosensitivity & precipitation of gout Ethambutol; must be avoided below 12 years. Retro-bulbar neuritis

 PAS;

GIT irrit ation Condition resembling Loefflers syndrome

S.M and capreomycin :

Renal & auditory nerve damage

Thioacetazone.

Steven-Johnson syndrome.

Synovitis & Early arthritis

Advanced arthritis

Surgical management
.
- A trial of conservative treatment is justified in most cases

before surgery

Non operative treatment is usually adequate in pure synovial tuberculosis (without involvement of articular cartilage), low grade /early arthritis of any joint and even advanced (stageIII & IV) arthritis. - Surgery should be done ATT cover & before development of drug resistance. In general minimum 3 - 4 wks ATT is advisable before any surgical intervention.

Indications
* Unresponsive cases of tubercular Synovitis subtotal synovectomy * Unresponsive cases of early arthritis synovectomy + joint debridment. Debridment should be limited to infected synovium, sequestrae, pus pockets & sinuses. * Advanced arthritis of hip in adult Excisional arthroplasty if acceptable range of movements are not obtained with ATT + P.O active / assisted movements are advised.

 ATT minimum of 1 year; preferably 18 months, in some cases 24 months If operation is anticipated or planned, avoid administration of > 2 hepato-toxic drugs (INH & Rifampicin) for 3 6 weeks prior to surgery. Halothane anaesthesia should be avoided in these pts.

Surgeries
* Drainage of cold abscess & excision of sinuses * Partial synovectomy + joint debridment * Corrective osteotomy (Add > 10o; Flex >30o) * Arthrodesis (Extra/ intracapsular) * Excisional arthroplasty * THR

Partial synovectomy + joint debridment

Indicated * Synovitis unresponsive to conservative treatment - Synovectomy * Early arthritis unresponsive conservative treatment Synovectomy + debridment
Complications of Partial synovectomy + debridment - AVN of femoral head, - SCFE in children, - # neck of femur or acetabulum

Corrective osteotomy
* Sound ankylosis in bad position upper femoral corrective osteotomy. * Unsound ankylosis (fibrous painful) in bad position - becomes osseous fusion (sound painless) by high femoral corrective osteotomy. It is simple extra-capsular procedure & can be done at any age * Ideal site for corrective osteotomy is near to the deformed joint.

Arthrodesis
* Direct intra-capsular fusion is favoured between raw surface of femoral head & acetabulum. * Classically indicated in adults presenting with painful fibrous ankylosis with active or healed disease.

- In children it should be deferred until growth ceases.

Ideal position of hip arthrodesis * Neutral position (between adduction & abduction) * 5 -10o ER * Flexion depending on age, from 10o (children) to 30o (adult)

A. In add - deformity ischio-femoral extra-articular fusion. B. In abd - deformity Ilio-femoral extra-articular fusion (easy to perform).

Drawbacks of arthrodesis
1. Limitation of activities (bending, sitting on floor, crossed leg
sitting, squatting , kneeling, sports, sexual mechanics (women) & by cycling)

2. Early degenerative changes

- in L-S spine, ipsilateral knee and contra-lateral hip.

3. Compensatory movements
- increased rotation of pelvis during sitting & walking - Increased flexion of ipsilateral knee during its stance phase. - Compensatory ligamentous laxity of ipsilateral knee (on long standing)

Excisional arthroplasty:
* Indians (Japan, south east Asia & middle east) dont accept stiff hip as it restrict squatting, sitting crossed legged & kneeling which are essential for socio-economic activity. * Girdle stones arthroplasty (in healed or active disease) after completion of bone growth, provide mobile, painless hip joint with control of infection and correction of deformity - Drawbacks - shortening (3.5 5.0 cm) & instability. * P.O traction for 3 mon minimize the shortening & gross instability. * Squatting, kneeling, cross- legged sitting, unsupportive stand on operated limb, lifting of limb against gravity and climbing with walking sticks are satisfactory. * 10% cases develop re- ankylosis.