tb hip grandround presentation.ppt
TRANSCRIPT
MUSCULOSKELETAL TB
HIP JOINT
FIRM III ORTHOPAEDIC GRANDROUND
DR. ONDARI N . J - ORTHO II
02-05-2013
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
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
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
Babcock's triangle
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
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”
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
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
GALLEAZI TEST
Nelaton's line
Bryant's triangle
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
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
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
TREATMENT Rest
Chemotherapy
Arthroplasty
Arthrodesis
Osteotomy
TREATMENT: REST Thomas urged that TB
should be treated by rest – which had to be ‘prolonged, uninterrupted, rigid and enforced’.
Hugh Owen Thomas
Treatment; Rest Traction
Provides rest of the joint Relieves muscle spasm Prevents and corrects deformity Maintains joint space Minimises chance of developing wandering acetabulum
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
Arthroplasty THR
Issues Reactivation of disease Duration of dz free interval before
arthroplasty Anti-TB use peri-arthroplasty
Excision arthroplasty
Arthrodesis Possible option in a young pt
with deformed hip
Brittain’s arthrodesis of the hip
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
THE END