TUBERCULOSIS of HIP JOINT

TUBERCULOSIS of HIP JOINTDr.T.Anil kumar2nd Year PostgraduateDepartment of OrthopaedicssiddssiddSiddhartha Medical CollegeVijayawada,AndhraPradesh

Historical aspects

ROBERT KOCH discovered Mycobacterium tuberculosis in 1882

IntroductionTB Hip 2nd only to spine Spine:Hip ratio 10:7Osteoarticular TB 1-3% of all TB cases ,of which TB hip 15-20% Primary focusTHR in active stage of disease another area of controversy

OrganismMycobacteria belong to the family- MYCOBACTERIACEAE Order ACTINOMYCETALESM.tuberculosis complex- - M.tuberculosis m/c human pathogen - M.bovis-bovine tubercle bacillus - resistant to Pyrazinamide - transmitted by unpasteurised milk-M.caprae,africanum,microti,pinnipedii,canetti

Organism ..M.tuberculosis - rodshaped,gram positive nonsporeforming, thinAEROBICbacilli 0.5m 3mOnce stained ,the bacilli cannot be decolorised by acid alcohol- thus called ACID FAST BACILLIAcid fastness is due to high content of MYCOLIC ACIDS,long chain cross linked fatty acids,other cellwall lipids

Organism - StructureIn the cellwall,lipids(mycolic acids) are linked to underlying ARABINOGALACTAN & peptidoglycans

Low permeability of cell wall

Reduced effectiveness of most antibioticsGenome comprises 4043 genes encoding 3993 proteins,50 genes encoding RNAs

Pathogenesis & Pathology Primary focus (Active/quiscent,Apparent/latent)

Hematogenous dissemination 2-3 yrs

Osteoarticular TB

Organism reaches joint space through either Subsynovial vesselsLesions in the epiphyseal bonesArticular cartilage destruction begins peripherallyTB Arthritis- doesnot form proteolytic enzymes in joint space central areas of articular cartilage preserved for long time

Common sites..

Initial focus may start in Acetabular roof m/cEpiphysis/Femur HeadMetaphyseal region Greater trochanter-least common

TB of GT may involve the overlying trochanteric bursa witout involving the hip joint for a very long timeUpper end of femur intracapsular joint involved rapidlyWhen initial focus starts in acetabular roof- joint involvement is late ,symptoms mild

Tubercle/Granuloma formation...Initial stages of infection- usually asymptomatic2-4wks after infection- 2 host responses1.Macrophage activated CMI: T-cell mediated response Activation of macrophages Killing & digesting tubercle bacilli2.Tissue damaging response DTH to various bacillary antigens - Destroys unactivated macrophages that contain multiplying bacilli

Insemination of infection

Accumulation of macrophages/monocytes

TB bacilli phagocytosed,broken down

Lipid dispersed throughout the cytoplasm

EPITHELOID cells large pale cells large vesicular nuclues Abundant cytoplasm LANGHANS GAINT cells

Mass formed by reactive cells - Nodule/TUBERCLE 2wks central CASEOUS NECROSISPresence of caseous necrosis SOFT TUBERCLENo caseous necrosis HARD TUBERCLE Rx, Atypical organism

Cold AbscessCollection of products of liquefaction & reactive exudationContains - serum, leukocytes, caseous material, bone debris,TB bacilliFeels warm ,but temperature not raised as high as in acute pyogenic infectionBursts Sinus/ulcer formation

Cold abscess forms within the joint inferior weaker part of the capsule

Perforated

Cold abscess presents anywhere around the hip femoral triangle Medial,lateral/ posterior aspect of thigh Ishcio rectal fossa Pelvis

Intra pelvic abscess

Below the levator ani Above levator ani

Ischiorectal fossa Upwards into inguinal region

Types of DiseaseCASEOUS EXUDATIVEMore destructionMore exudation & abscess formationInsidious onsetMarked constitutional featuresGRANULARLess destructionAbscess formation rareInsidious onset & courseDRY lesion

Fate of tubercleResolve completelyHeal completely with residual deformities/ loss of functionLesion completely walled off,caseous tissue calcifiedLow grade chronic fibromatous, granulating & caseating lesion may persistInfection spreads contiguous,systemically

Clinical features..Commonest age : 1st 3 decadesLimping earliest,commonest symptom - Antalgic gaitPain reffered to medial aspect of knee - max towards end of the dayDeformity Fullness around the hipNight cries sleep awakening

Classification

Synovitis stage..

Position of max joint capacity FABERApparent LENTHENINGOnly extremes of movement are painfulDD Traumatic synovitis - Nonspecific Transient Synovitis - Low grade pyogenic infection - Perthes disease - SCFEUSG repeated at 2-3 wksX-Rays: soft tissue sweling,Rarefaction

Early Arthritis stage..Articular damage startsSevere muscle spasm- FADIRApparent shorteningRestriction of movements in all directionsAppreciable muscle wastingMRI synovial effusion - minimal ares of bone destruction - osseous oedemaX-Rays: OSTEOPENIA, marginal bony erosions NORMAL JOINT SPACE

Advanced Arthritis ..

FADIRTrue shortening severity of symptomsCapsule further dstroyed ,thickened & contractedX-Rays : Destruction of articular surface Joint space

Advanced arthritis with Subluxation / DislocationWith further destruction of acetabulum, femur head ,capsule & ligaments the upper end of femur is displaced upwards & dorsally in the wandering / migrating acetabulum leaving its lower part empty & broken Pathological dislocation of femur headMovements are grossly restricted

Classification - Radiological appearenceShanmugasundaram in 1983 classified the radiological appearences as Type 1 - normal (C)Type 2 Travelling/ wandering acetabulum(C,A)Type 3 Dislocating type(C)Type 4 Perthes type(C)Type 5 Protrusio acetabuli(C,A)Type 6 Atrophic(A)Type 7 Mortar & Pestle type(C,A)

Shanmugasundarams Classification

PROTRUSIO TYPE

ATROPHIC TYPE

If the disease occurs during chilhood Chronic hyperaemia Enlarged femoral head epi & metaphysis COXA MAGNAThrombo embolic phenomenon of selective terminal vasculature changes similar to PERTHES diseasea)Gross blood supply of femoral head due to TE b) Rapidly developing tense IC effusion (Tamponade effect) reduced femoral head & neck size COXA BREVA

Restricted growth of epiphyseal plate & normal trochanteric growth plate COXA VARA

Restricted trochanteric growth & normal femoral head COXA VALGA

Close relationship b/w radiological type & therapeutic outcome:Normal type - 92% good resultsPerthes type - 80% good resultsDislocating type 50% good resultsTravelling acetabulum & Mortar pestle type - 29% good results

EvaluationHematological ESR,relative lymphocytosisBacteriological AFB staining & C/SSerological ELISA serum IgG,IgM Histology HPE for TUBERCLE Molecular PCR using 16sr RNAClinico radiological : X-Rays, CT Scan MRI USG

Synovial fluid aspiration AFB positive in 10 20% of cases Cultures positive in 50% of cases Aspiration of cold abscess for microbiologySynovial Biopsy More reliable Cultures positive in 80% cases Histology : granulomatous inflammation

Hip joint aspiration..

Bacteriological diagnosis..Specimen stained for AFB & C/SStains used: - ZIEHL NEELSEN stain - Auramine Orange fluorescenceMedia used for growth: Lowenstein- Jensen Conventional AFB C/S 4wks - requires live organism - long incubation period - low sensitivity in pts already on ATTNewer rapid culture tech- BACTEC

BACTEC : Radiometric culture system

Detects Mycobac as early as 7-14 days

Based on release of radiolabelled CO2 from the growth of Mycobac in selective LIQUID media using C14labelled sustrate

Diagnosis Clinico radiological in endemic areasPaucibacillary Disease Bacteriological diagnosis is possible in 10-30% cases onlyHPE & PCR diagnosticEmerging MDR strains threat to cure the TB lesion , thus TB bacilli should be isolated & subjected to drug susceptibility

Serology..IgM diagnostic of activity of the diseaseIgG diagnostic of chronic disease/healed disease - levels remain high even after full RxELISA antibody values are dependent on - time of taking sample - state / phase of the diseaseAntibody titres donot correlate with recovery status of the patient.

Molecular diagnosis..PCR single test which amplifies the genome even if a single organism was presentIdeal for detection of paucibacillary TB caseMany target genes of Mycobacteria16sr RNA used as target sequence as it is universally present false negative - genus specific marker

Advantages of PCR..Highly efficient & rapid method for Dx 3daysGreat value in early DxVery sensitive tech could detect as few as 1-2 mycobac in the specimen , and Rx initiated based on this result if clinical signs of disease presentCan differentiate typical from atypical mycobacRequires very small quantity of specimen even microlitres of FN aspirate can be tested

Disadvantages ..Notable to differentiate live from dead org, as it is not dependent on bac replicationDoesnot tell about the activity of the disease

PCR positive results doesnot always confirm to culture resultsPCR not a substitute for culture

Culture gold standardCT guided FNAC useful & minimally invasive method of ascertaining HP DxScreening tests : Tuberculin skin test/Mantoux testInterferon gamma release assay (IGRA)

Tuberculin skin test.. Purified protein derivative (PPD) of tuberculin (Antigenic culture extract) injected intradermally 0.1ml into volar / dorsal aspect of forearm(0.1ml = 0.0002mg PPD)Results read after 48-72 hrsPositive : > 10mm indurationMeasures delated hypersensitivity

Causes of false negative PPD test : Age > 70 yrsSteroid use( Prednisolone >15mg/day)Hypoalbunemia( 18yrs ageTypes : 1.Intra articular 2.Extra articular if Adduction Ischio femoral - if abduction Ilio femoral 3.Combined intra extra articular

During extra articular arthrodesis ,upper femoral corrective osteotomy can also be performed brings limb into functional positionIntraarticular arthrodesis permitsExploration of jointExcision of diseased tissueCurretage of juxta articular infected tissue

Operative tech IA arthrodesisStandard anterolateral approachGrossly diseased capsule,synovium removedJoint dislocated carefullyExcise cartilage ,subchondral bone from femoral head & acetabulum down to cancellous boneRepose the rawed head into freshened acetabular cavity,place cancellous bone graft all around the joint

Keep the joint in best functional position & insert 2-3 long steinmann pins from base of GT femoral neck & head going into acetabulumApply hip spicaAfter 6-8wks pins removedGradual Wt bearing with POP on, is started using crutchesImmobilisation & wt bearing continued for 4-6 months

Very difficult to perform conventional arthrodesis if extensive destruction / sequestration of femoral head & neckRx ABBOTT LUCAS tech of fusion of hip in 2 stages

Abbott & Lucas arthrodesisCan be done in active infectionATT cover is mandatory1ST STAGE : Anterior Smith Peterson approachRemove capsule & debride jointRemove femur neck stump& denude GT Debride GT & acetabulum to bleeding cancellous bone, then place GT into acetabulum with limb in wide abduction30-90 deg abduction may be necessary, av -45deg

2nd STAGE: 4-8 wks later, osteotomy carried abt 5 cm below LT through lower end of previous incisionDistal fragment is usually displaced slightly medially to allow a part of proximal fragment to fit into medullary canal of distal fragment Apply hip spica which is removed after consolidation

Brittains tech of EA arthrodesisExpose proximal femur laterally,stay out of involved joint capsulePerform subtrochanteric osteotomy angling upwards towards ischium beneath the involved acetabulumWith a currette,fashion a hole in the ischium below the involved hip joint capsule & drive the tibial graft across osteotomy site into ischium

No internal fixation is usedHip spica applied After 8th wk post op walking is undertaken in the cast for upto 6months till fusion occurs

Disadvantages of arthrodesisEarly development of degenerative osteo arthrosis in LS spine,ipsilateral knee, contralateral hipCompensation for fused hip : Rotation of pelvis flexion of ipsilateral knee during stance phase

Activities max limited after fusion bending,sitting on floor, cross legged sitting ,Squatting,kneeling,bicyclingThus no pt would accept a fused joint

Excision arthroplasty..GIRDLESTONE described excision of femoral head,neck,proximal part of trochanter & acetabular rim for chronic dep seated infections of hip jointCan be safely carried out in healed / active disease after growth completionProvides mobile ,painless hip with control of infection ,correction of deformity

Some degree of SHORTENING, INSTABILITYMean loss of length 1.5 cmShortening by postop prolonged TRACTION in 30-50 deg of abduction upto 3monthsTECTOPLASTY improves instabilityMILCH - pelvic support osteotomy at the level of ischeal tuberosity ,also reduces instability

Hip replacement in TB ..THA in active infection controversial due to risk of reactivationMost authors suggest THA atleast 5-10 yrs after the last evidence of active infectionReactivation of infection - 10-30% casesTHA in healed TB Hip is now acceptedMajority perform it in the stage of advanced arthritis / its sequelae, when joint is unsalvageable

Wang et al combination of ATT for atleast 2wks preop & for atleast 12months post op - THA in advanced active TB hip is a safe procedure with symptomatic relief & functional improvement Sidhu et al THA in active TB Hip is a safe procedure when perioperative ATT was used - adequate surgical debridement , ATT Key for successful outcomeKim et al no difference in reactivation / healing with cemented /cementless implants

Rx in chidren..Synovitis & early arthritis ATT - Traction - bed rest - supportive Rx Management in advanced joint destruction , wandering acetabulum,or with pathological subluxation is difficult & controversial

Rx in children..In children with arthritis Traction failure Open arthrotomy Synovectomy Debridement of diseased jointArthrodesis deferred till growth completion

In children with healed disease & gross deformity ,(flexion -30,Adduction >30, Abduction >10 deg)

extra articular corrective osteotomy

References ..Tuberculosis of the skeletal system SM Tuli 4th edTB Hip current concepts review- Shyam kumar Saraf,SM Tuli IJO Jan 2015/vol 49/issue 1 Tuli SM.MDR TB A challenge in clinical orthopedics. IJO2014;48;235-7TB of Musculoskeletal system David A.Speigel,Girish.K.Singh,Ashok k .Bansota Tech in Orthopedics20(2);167-178,2005

Evaluation of clinico-radiological,bacteriological,serological,molecular and histological diagnosis of OA TB Anil k Jain,Santosh kumar Jena,MP singh- IJO-April-June 2008/volume42/issue2WHO-Global Tuberculosis report-2014Campbells operative Orthopaedics -12th edPathological basis of disease- Robbins & Cotran -8th ed Color atlas of clinical orthopaedics-Milkos Sezendroi,Franklin H Sim,2009National health programs of india J. Kishore, 11edHarrisons Principles of internal medicene -18th ed