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MUSCULOSKELETAL TB
HIP JOINT
FIRM III ORTHOPAEDIC GRANDROUND
DR. ONDARI N . J - ORTHO II
02-05-2013
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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 professionShanmugasundaram T K
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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
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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 bony lesion invades the joint early
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Babcock's triangle
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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
Within fibrocaseous mass mycobacteria may remain with potential of flare many years later
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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”
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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
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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
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GALLEAZI TEST
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Nelaton's line
Bryant's triangle
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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
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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 Fibrous ankylosis
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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
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TREATMENT
Rest
Chemotherapy
Arthroplasty
Arthrodesis
Osteotomy
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TREATMENT: REST
Thomas urged that TB should be treated by rest – which had to be ‘prolonged, uninterrupted, rigid and enforced’.
Hugh Owen Thomas
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Treatment; Rest
Traction
Provides rest of the joint Relieves muscle spasm Prevents and corrects deformity Maintains joint space Minimises chance of developing wandering acetabulum
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TB disease category
Intensive phase
Continuation phase
All forms of PTB and EPTB except TB meningitis and osteoarticular TB
2RHZE 4RH
TB meningitis,
osteoarticular TB
2RHZE 10RH
New WHO Recommended regimen
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Arthroplasty
THR Issues
Reactivation of disease Duration of dz free interval before
arthroplasty Anti-TB use peri-arthroplasty
Excision arthroplasty
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Arthrodesis
Possible option in a young pt with deformed hip
Brittain’s arthrodesis of the hip
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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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THE END