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Musculoskeletal tb hip joint FIRM III orthopaedic GRANDROUND dr
Musculoskeletal tb hip joint FIRM III orthopaedic GRANDROUND dr. ondari n . J - ortho ii
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Tuberculosis is probably as old as mankind.
It's continued presence midst us is a sorry tale of missed opportunities and mismanagement by the medical profession Shanmugasundaram 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 The anatomical sites of the lesions could be: the superior rim of the acetabulam, which is drained by the communicating venous channels of the Batson's prevertebral venous plexus and (b) Babcock's triangle limited by the inferior neck of femur, medially by the epiphysial line or equiva- lent stress lines in adults and laterally by the stress trabeculae of the neck of the femur which is intra- articular in location. Skeletal lesion can occur in the head and neck of femur, in the greater trochan- ter. Rarely, the lesion could be purely synovial in location.
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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
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 ) The mnemonics indicate the orientation and appearance of the lower limb during those stages of TB FABER - AL === stands for flexion , abduction , external rotation and apparent lengthening . FADIR - AS === stands for flexion , adduction , internal rotation and apparent shortening . FADIR - TS === stands for flexion , adduction , internal rotation and true shortening.
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In Stages II and III of the disease, the radiologic features are very obvious and diagnostic, and almost always predict the final clinical outcome
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The tuberculosis of hip mainly progresses through three stages
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 Later 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’. Treatment REST Hugh Owen Thomas long ago urged that tuberculosis should be treated by rest – which had to be ‘prolonged, uninterrupted, rigid and enforced’. This often involved splintage of the joint and traction to overcome muscle spasm and prevent collapse of the articular surfaces. With modern chemotherapy this is no longer mandatory; rest and splintage are varied according to the needs of the individual patient. Those who are diagnosed and treated early are kept in bed only until pain and systemic symptoms subside, and thereafter are allowed restricted activity until the joint changes resolve (usually 6 months to a year). Those with progressive joint destruction may need a longer period of rest and splintage to prevent ankylosis in a bad position; however, as soon as symptoms permit, movements are again encouraged 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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New WHO Recommended regimen
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 10RH
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Arthroplasty THR Excision arthroplasty 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 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
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