Tuberculosis of hip: A current concept review

Abstract

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.

Keywords: Tubercular arthritis; Tubercular osteoarticular; arthroplasty; children; hip; hip prosthesis; total hip replacement.

Figure 1

Diagrammatic representation of the location of osseous origin of tuberculosis of left hip joint; (1) acetabulum (2) femoral head/epiphysis (3) femoral neck/metaphysic (4) greater trochanter (reprinted with permission from Tuli[1])

Figure 2

Plain X-ray showing “stage of arthritis;” pathology involving articular surface. Irregular and hazy joint margins with diminished joint space on left side

Figure 3

X-ray left hip joint anteroposterior view showing the “wandering acetabulum”

Figure 4

X-ray pelvis with both hip joints showing the “Perthes type” of appearance on left side

Figure 5

X-ray of right hip joint anteroposterior view showing (a) active tubercular arthritis of right hip. (b) After Girdlestone excision arthroplasty

Figure 6

X-ray pelvis with both hip joints anteroposterior view showing (a) tubercular arthritis of left hip. (b) After uncemented total hip arthroplasty (with permission from A K Rai, BHU)

Figure 7

Schematic diagram of steps of tectoplasty. (a) The outer cortex of ilium is split away from the inner cortex and reflected outwards. The cavity thus created is filled up with bone graft. (b) Sectional diagram to show the aim of the operation (reproduced from Saito et al.24)

Figure 8

X-ray left hip anteroposterior view showing (a) old healed tubercular arthritis hip with dislocation. (b) Tactoplasty after pulling the head down. For initial six weeks, temporary stabilization is provided by k wire fixation, to be removed around 6 weeks