Total hip replacement in tuberculosis of hip: A systematic review

Functional outcome of total hip arthroplasty in tubercular hip arthritis: A prospective study

Background

Total hip arthroplasty (THA) is a well-established procedure to cure tubercular hip arthritis in patients with healed tuberculosis while its role in active tuberculosis is still debatable. The aim of the study is to investigate the functional outcomes of THA in active tuberculosis with advanced hip arthritis. The reactivation of tuberculosis and complications postoperatively has also been assessed.

Materials and methods

The current open-ended prospective cohort study was carried out at a tertiary center from 2018 to 2020. Twenty patients of active tubercular hip arthritis (8 females and 12 males) were taken with a follow-up period ranging from 1 year to 3 years, with a mean of 14 months.Biochemical investigations were done both preoperatively and postoperatively. Preoperative anti-tubercular therapy (ATT) regimen was administered, as per standard norms, to patients for a minimum period of 6 weeks, and postoperatively for 6 months-12 months. Postero-lateral and Hardinge approaches were employed in all cases. Clinical and radiological parameters were assessed and functional outcomes were evaluated using the Harris Hip score (HHS).

Results

The mean age of patients was 37.6 ± 11.38 years. Biochemical parameters were also found to improve postoperatively (p < 0.0001). The mean flexion, extension, abduction, external and internal rotation were found to increase postoperatively (p < 0.001). The mean flexion deformity in the preoperative period was 12.35 ± 4.716, whereas none of the patients had flexion deformities post operatively. The mean shortening was 2.12 ± 0.60 and 1 ± 0 at preoperative and postoperative respectively. The Total hip arthroplasty implant was found stable in all patients. The mean Harris score increased subsequently throughout the follow-up interval and differences were statistically significant (p < 0.0001). None of the patients had reactivation of tuberculosis infection postoperatively.

Conclusion

Total hip arthroplasty is a reliable option to treat active advanced tubercular hip arthritis and gives good functional outcome with proper preoperative and postoperative ATT regimen.

Total hip arthroplasty in active and advanced tubercular arthritis: a systematic review of the current evidence

STUDY DESIGN

Systematic review.

INTRODUCTION

Total hip arthroplasty (THA) is a well-acknowledged surgical intervention to restore a painless and mobile joint in patients with osteoarticular tubercular arthritis of the hip joint. However, there is still substantial uncertainty about the ideal management, clinical and functional outcomes following THA undertaken in patients with acute Mycobacterium tuberculosis (TB) hip infections.

AIM OF THE STUDY

To undertake a systematic review and evaluate existing literature on patients undergoing THA for acute mycobacterium tuberculosis arthritis of the hip.

METHODS

A systematic review of electronic databases of PubMed, EMBASE, Scopus, Web of Science and Cochrane Library was performed on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The search focused on "arthroplasty in cases with tuberculosis of hip joint" since inception of databases until July 2023. Data on patient demographics, clinical characteristics, treatment administered, surgical interventions and outcome, as reported in the included studies, were recorded. Median (range) and mean (standard deviation) were used to summarise the data for continuous variables (as reported in the original studies); and frequency/percentage was employed for categorical variables. Available data on Harris hip scores and complications were statistically pooled using random-effects meta-analysis or fixed-effect meta-analysis, as appropriate RESULTS: Among a total of 1695 articles, 15 papers were selected for qualitative summarisation and 12 reporting relevant data were included for proportional meta-analysis. A total of 303 patients (mean age: 34 to 52 years; mean follow-up: 2.5 to 10.5 years) were included in our systematic review. In a majority of included studies, postero-lateral approach and non-cemented prosthesis were employed. Fourteen studies described a single-staged procedure in the absence of sinus, abscess and tubercular infection syndrome (TIS). All surgeries were performed under cover of prolonged course of multi-drug anti-tubercular regimen. The mean Harris hip score (HHS) at final follow-up was 91.36 [95% confidence interval (CI): 89.56-93.16; I2:90.44%; p<0.001]. There were 30 complications amongst 174 (9.9%) patients (95% CI: 0.06-0.13; p=0.14; I2=0%).

CONCLUSION

THA is a safe and effective surgical intervention in patients with active and advanced TB arthritis of hip. It is recommended that the surgery be performed under cover of multi-drug anti-tubercular regimen. In patients with active sinus tracts, abscesses and TIS, surgery may be accomplished in a multi-staged manner. The clinical (range of motion, deformity correction, walking ability and pain scores), radiological (evidence of radiological reactivation and implant incorporation) and function outcome (as assessed by HHS) significantly improve after THA in these patients.

Total hip arthroplasty in different types of advanced tubercular hip arthritis: is it justified

PURPOSE

Total hip arthroplasty (THA) provides a good treatment option for the patients in late arthritis stage. We present our experience of THA in various spectrums of disease.

METHODS

Retrospective study including 23 advanced tubercular hip arthritis patients over a period of 13 years. The patients with active discharging sinus were excluded from the study. The patients were divided into three groups: group 1 (healed TB), group 2 (active TB), and group 3 (intraoperative surprise). The preoperative and postoperative antitubercular treatment (ATT) was administered to all the patients as per the protocol for various duration. All patients underwent THA (cementless or hybrid) after investigations including MRI. The patients were followed up with clinic-radiological and laboratory investigations.

RESULTS

The mean age of the patients was 58.2 years with 16 males and seven females. There were 14 healed TB hips, eight active TB hips, and one intraoperative TB hip patient. Preoperative ATT duration in group 1 varied from one to two weeks and in group 2 patient's average was 9.6 weeks (range: 6-12weeks). Postoperatively, ATT was given for a minimum of ten months extending to 16 months. Cementless THA was performed in 17 patients and hybrid THA (cemented stem) in six patients. Only one patient had aseptic loosening of the stem and revision arthroplasty was done.

CONCLUSION

THA is a viable option and provides mobile, stable hip in tubercular hip arthritis even in active TB hip patients. ATT is important in the management and prevent the reactivation of the disease.

A sustained release lubrication method of agarose-sodium hyaluronate hydrogels for artificial joint

The artificial joint prosthesis's surface is subjected to wear due to the destruction of the joint lubrication environment after surgery. In this study, an agarose-sodium hyaluronate hydrogel was used as lubricant additive in order to supply and preserve the lubricating fluid of artificial joint prostheses. A ball on disc experiment was conducted using this hydrogel to evaluate the lubrication efficiency and release rate under various frequencies. The results showed that this hydrogel could release lubricant under pressure and then absorb the released fluid after decompression. Furthermore, the agarose-sodium hyaluronate hydrogel acted as an effective transport mechanism to release sodium hyaluronate lubricant into the metal-on-polymer friction interface. Compared with pure water lubrication, the friction coefficient and wear volume were reduced by up to 62.9%, and 86.9% respectively. Moreover, the proposed lubrication method provided a long-term lubrication on artificial hip joints.

Short-term outcomes of one-stage debridement and fusion for ankle joint tuberculosis

PURPOSE

Tuberculosis remains a worldwide health problem, as well as its complications including arthritis in various joints. End-stage arthritis in weight-bearing joint would require surgery either arthroplasty or arthrodesis, in order to achieve painless and stable gait. In general, staged surgery consisted of debridement and subsequent definitive procedure is accepted. However, multiple surgery would be disadvantageous in terms of clinical and economic burdens. This study reported the short-term result of one-stage debridement and fusion for ankle joint tuberculosis.

METHODS

Retrospective evaluation of twenty-six patients with history of one-stage debridement and ankle fusion was conducted. Basic anthropometric measurement, local status, and surgical technique were recorded. Functional score using Foot and Ankle Ability Measures (FAAM) activities of daily living (ADL) was assessed pre-operatively and at two and half year post-surgery follow-up visit along with radiological fusion rate. Paired t test was used to analyse the improvement of the clinical scores.

RESULTS

There was improvement in FAAM score from 43.38 ± 9.51 to 62.19 ± 6.63% (p < 0.001). All sinuses had been subsided, albeit at various time spans. Modified radiographic union score for tibia (RUST) revealed various fusion rate results, ranged from 5 to 11.

CONCLUSION

One-stage debridement and fusion is proven efficacious for end-stage joint tuberculosis, with less surgery occasion compared with staged surgery. However, patient selection is important since any comorbidities or secondary infection may complicate the fusion.

Total Hip Replacement in Active and Inactive Tuberculosis Hip: A Systematic Review

Introduction

Tuberculosis of the hip joint is a debilitating disease that can result in severe joint destruction, eventually leading to painful arthritis of the hip. Total hip arthroplasty (THA) in patients with advanced arthritis offers a painless and mobile joint with good functional outcome but some aspects of THA in TB hip have been controversial in the past due to the concerns of disease reactivation, especially when disease activity is factored in. Various factors like timing of surgery, Antitubercular therapy (ATT) initiation timing, reactivation, complications etc needs to be evaluated very carefully before planning for such cases.

Methods

Electronic databases like MEDLINE, EMBASE, Cochrane library, Clinicaltrials gov and OpenGrey were searched. The key words used were "Tuberculosis", "Tuberculosis of hip", Hip tuberculosis, "TB", "THR", "total hip replacement", "total hip arthroplasty","THA", "ankylosed hip", "fused hip", "arthrodesis" along with boolean operators "AND" and "OR". Out of a total of 1634 articles, 38 were selected for full text review and 22 articles were finally included in the study.

Results

For the timing of surgery most authors relied on the inflammatory markers to settle down with ATT before performing THA. 15 authors advocated use of pre-operative ATT with 6 studies recommending at least 2 weeks and 3 studies advocating atleast 3 months of ATT pre surgery.Single stage THA was performed in most studies(214 hips vs 18 hips) as opposed to 2 or 3 stage surgery. In the active disease 72.8% of the hips had uncemented prosthesis, 25.6% hips underwent cemented and 1.5% hips had hybrid THA fixation. Overall reactivation of the infection was seen in 2.47% cases. All authors reported excellent clinical improvement (mean HHS improvement 37.17 to 88.62).

[Antifriction and anti-wear performances of bionic lubricating fluid containing gelatin nanoparticles for artificial joint materials]

Objective

The antifriction and antiwear effects of gelatin nanoparticles (GLN-NP) on artificial joint materials in bionic joint lubricant were investigated to provide a theoretical basis for the development of new bionic joint lubricant.

Methods

GLN-NP was prepared by cross-linking collagen acid (type A) gelatin with glutaraldehyde by acetone method, and the particle size and stability of GLN-NP were characterized. The biomimetic joint lubricants with different concentrations were prepared by mixing 5, 15, and 30 mg/mL GLN-NP with 15 and 30 mg/mL hyaluronic acid (HA), respectively. The friction reduction and antiwear effects of the biomimetic joint lubricants on zirconia ceramics were investigated on a tribometer. The cytotoxicity of each component of bionic joint lubricant on RAW264.7 mouse macrophages was evaluated by MTT assay.

Results

The particle size of GLN-NP was about 139 nm, and the particle size distribution index was 0.17, showing a single peak, indicating that the particle size of GLN-NP was uniform. In complete culture medium, pH7.4 PBS, and deionized water at simulated body temperature, the particle size of GLN-NP did not change more than 10 nm with time, indicating that GLN-NP had good dispersion stability and did not aggregate. Compared with 15 mg/mL HA, 30 mg/mL HA, and normal saline, the friction coefficient, wear scar depth, width, and wear volume were significantly reduced by adding different concentrations of GLN-NP ( P<0.05); there was no significant difference between different concentrations of GLN-NP ( P>0.05). Biocompatibility test showed that the cell survival rate of GLN-NP, HA, and HA+GLN-NP solution decreased slightly with the increase of concentration, but the cell survival rate was more than 90%, and there was no significant difference between groups ( P>0.05).

Conclusion

The bionic joint fluid containing GLN-NP has good antifriction and antiwear effect. Among them, GLN-NP saline solution without HA has the best antifriction and antiwear effect.

Total hip arthroplasty after seven decades of a Girdlestone situation due to tuberculous coxitis in childhood

Introduction

Tuberculous coxitis accounts for about 15% of all osteoarticular tuberculosis cases and is the second most common after spinal tuberculosis. In extensive cases, Girdlestone resection arthroplasty is an option for primary surgical treatment followed in the course of time, with total hip arthroplasty (THR) to increase function. However, the remaining bone stock is generally poor. In these cases, the Wagner cone stem offers good pre-conditions for bone restoration even seven decades after Girdlestone, as presented here.

Case Report

A 76-year-old male patient was admitted to our department with a painful hip, who had previously been treated with Girdlestone at the age of 5 years after being diagnosed with tuberculous coxitis. After an intensive and very detailed evaluation of treatment options, the decision fell on rearticulating with a THR, even though primary surgery lay seven decades back. Since it was not possible to insert an appropriate non-cemented pressfit-cup, an acetabular reinforcement ring and a PE low profile cup were inserted, cemented with less inclination to avoid or reduce hip instability. A fissure around the implant (Wagner cone stem) was secured with numerous cerclages. Surgery was performed by the senior author (A.M.N.) postoperatively, the patient suffered a prolonged delirium. Ten months after surgery, the patient was satisfied with the result and reported a meaningful improvement in his daily quality of life. His mobility increased significantly and represented by his ability to climb stairs without being in pain or needing walking aids. Today, 2 ½ years after THR surgery, the patient still reports being satisfied and pain free.

Conclusion

Despite transient complications postoperatively, we are happy to report a very satisfactory clinical and radiologic outcome after 10 months. The today 79-year-old patient reports having a higher quality of life since rearticulation of his Girdlestone situation. However, the long-term effects and survival rate of this procedure need to be observed furthermore.

Early clinical outcomes of one-stage total hip arthroplasty for the treatment of advanced hip tuberculosis

OBJECTIVE

To investigate the clinical efficacy of one-stage total hip arthroplasty (THA) for treating the advanced hip tuberculosis.

METHODS

A retrospective study was conducted from July 2013 to June 2018, including 19 patients with advanced hip tuberculosis. All patients underwent total hip arthroplasty through posterior approach, and the surgical efficacy was evaluated.

RESULTS

Nineteen patients were followed up from 24 months to 48 months, the mean follow-up were 32.1 months. All the incisions healed in grade A. There were no aseptic loosening, dislocation or recurrence of hip tuberculosis after operation. At the last follow-up, the Harris score of the patients was (89.3 ± 6.7), which was significantly higher than (38.2 ± 10.5) of the patients before operation (P < 0.05); the flexion-extension range of motion was (93.6° ± 12.1°), which was significantly larger than (38.2° ± 10.5°) of the patients before operation (P < 0.05).

CONCLUSION

The one-stage total hip arthroplasty with regular antituberculosis treatment can attain satisfactory clinical efficacy in the treatment of advanced hip tuberculosis, which can relieve the joint pain and improve the joint function, without recurrence of hip tuberculosis.

Effect of continuous nursing combined with salcatonin on postoperative pains in elderly patients after hip replacement

OBJECTIVE

This study was designed to explore the effect of continuous nursing combined with salcatonin on the improvements of postoperative pain in elderly patients after hip replacement.

METHODS

A total of 99 elderly patients treated by hip replacement in our hospital were divided into the control group (CG, n=49, routine nursing + salcatonin) and the study group (SG, n=50, continuous nursing + salcatonin). The visual analogue scale (VAS) during rest (RVAS), VAS during initiative movement (IVAS) and VAS during passive movement = (PVAS) at 3 d, 7 d, 10 d, 14 d and 30 d after operation, the Harris hip score (HHS), Barthel index and geriatric depression scale (GDS) at 1 month after operation, and the incidences of tumble and refracture during the postoperative 6-month follow-up were compared between the two groups.

RESULTS

In comparison with the CG, except for higher HHS and Barthel index at 1 month after operation (P<0.05), the SG was associated with lower RVAS, IVAS and PVAS at 7 d, 10 d, 14 d and 30 d after operation (P<0.05), lower GDS at 1 month after operation, and lower incidences of tumble and refracture during the 6 months after operation (P<0.05).

CONCLUSION

The combination of continuous nursing and salcatonin has achieved marked effects not only on mitigating the pains at the early stage after a hip replacement in elderly patients, but also on improving their joint functions and reducing the incidences of tumble and refracture in a long run.

Total hip arthroplasty in tubercular arthritis of the hip - Surgical challenges and choice of implants

Osteoarticular tuberculosis of the hip joint can be a debilitating disease that can result in severe cartilage degeneration, destruction, and eventual painful arthritis of the hip. Usually, a secondary affliction to a primary lung disease, Tuberculosis (TB) of the hip can be difficult to diagnose due to its indolent natural history and deep-seated nature of the hip joint itself. Untreated, ultimately TB hip leads to disabling arthritis of the hip with limitation of activities of daily living, livelihood, and socio-economic consequences. Historic surgical options such as arthrodesis and excision arthroplasty of TB hip have limitations and several disadvantages. Total hip arthroplasty (THA) is a viable option to restore mobility and relieve pain in patients with severe post-tuberculous arthritis but has been controversial in the past due to the concerns of disease reactivation. We evaluate the current role of THA in TB of the hip, its various applications in different presenting scenarios with a guide to surgical tips and tricks for managing this challenging condition.

Mid-Term Outcomes of Cementless Total Hip Arthroplasty in Adult Patients with Childhood Hip Infection

BACKGROUND Patients with hip joint infections in childhood often have many aftereffects of different degrees, regardless of the kind of treatment or natural course. Total hip arthroplasty is currently the most effective treatment for sequelae of childhood hip septic or tuberculous infection. This is a mid-term follow-up study of treatment results of patients who had undergone total hip arthroplasty (THA) with cementless prostheses. MATERIAL AND METHODS We retrospectively analyzed and followed 45 patients (45 hips) who underwent THA with cementless prostheses between 2010 and 2017. There were 45 patients, including 17 men and 28 women. The average age of the patients was 46 years (range, 18-67 years). All hip infections occurred in early childhood or adolescence, and the mean interval between initial infection and THA was 38.2 years (range, 15-60 years). The mean follow-up was 6.1 years (range, 2.7-9.5 years). RESULTS Two patients underwent revision surgery because of loosening of the prosthesis, and 1 patient underwent revision surgery because of a new infection with no relationship with childhood infection during the follow-up. The average Harris hip scores significantly increased from 43.1 to 86.4 (P<0.01), and the average visual analog scale significantly increased from 4.6 to 1.7 (P<0.01). The hip dysfunction and osteoarthritis outcome scores were also significantly changed (P<0.01) at the final follow-up. There were 2 cases of transient sciatic nerve palsy and intraoperative periprosthetic fractures in 3 cases. During follow-up, single revision was performed after 6 years of primary arthroplasty because of aseptic loosening in 2 cases and prosthesis infection in 1 case, which was not related to childhood pathogens. CONCLUSIONS THA for patients with sequelae of hip joint infection has a satisfactory effect that can effectively relieve joint pain and improve hip function. The recurrence rate of infection after either pyogenic infection or tuberculous is very low. The mid-term outcomes of THA in this setting were satisfactory, with high prosthesis survivorship and hip function scores.

Tubercular arthritis presenting as osteonecrosis of the femoral head: A case report

A tuberculosis hip that presents as osteonecrosis of the femoral head is an extremely rare condition. There are no previous reports of this condition, and there is no consensus on the method of total hip arthroplasty for this group of patients. We present a case of a 72-year-old man who had clinical gradual hip pain in both hips for 1 year. He was diagnosed with post-collapsed osteonecrosis of the femoral head in both hips and was scheduled for total hip arthroplasty of the left hip. During his clinical follow-up, he suddenly experienced excruciating acute pain. Investigation to rule out infection was positive for only C-reactive proteins, but his synovial fluid work-up was negative. An intraoperative finding revealed that there was collapse of the femoral head with eroded acetabular cartilage and rice body–like synovitis. Total hip arthroplasty was performed, and the tissue was sent for diagnosis. Tissue acid-fast bacilli were positive, so the patient received anti-tuberculosis drugs for 9 months, with no recurrent infection. Tuberculosis arthritis presenting as osteonecrosis of the femoral head is a complex condition that is difficult to diagnose due to the radiographic pictures of femoral head collapse and arthritic change being similar in both diseases. Acute pain onset with rapid collapse of the femoral head should be a consideration or suspect for this infectious condition. Hence, investigation to rule out infection is important. Anti-tuberculosis drugs are the standard treatment for early or advanced arthritis, and one-stage or two-stage total hip arthroplasty is the choice of treatment for advanced arthritis.

Clinical and MRI response to dose reduction of an etanercept-biosimilar for hip arthritis in patients with ankylosing spondylitis: an observational, retrospective cohort study

OBJECTIVES

Hip arthritis plays a critical role in the prognosis of ankylosing spondylitis (AS). Dose reduction of tumor necrosis factor inhibitors preserves general improvement of AS, so this study attempted to examine the equivalence between Yisaipu® tapering and conventional therapy for hip arthritis in AS patients, using clinical parameters and magnetic resonance image (MRI).

METHODS

AS patients received this etanercept-biosimilar injections (50 mg/week) in the first 12 weeks. Participants in the tapering group were treated with this reagent 50 mg every other week from week 13 to week 24, while the control group kept undergoing full-dose therapy. Clinical and laboratory parameters were assessed at baseline, week 12 and week 24. MRI examination of hip was performed at baseline and week 24.

RESULTS

One hundred and thirty-six patients were enrolled, and 80 of them were in the tapering group. Linear mixed model revealed that main effects of tapering group with control group as reference in disease activity parameters were insignificant (p > 0.05). Main effects of baseline with week 24 as reference were significant (p < 0.05), but main effects of week 12 with week 24 as reference were not (p > 0.05). Prevalence of acute inflammatory change in MRI significantly decreased in the tapering group (76.88% vs 20.00%, p < 0.05) and control group (76.79% vs 19.64%, p < 0.05). Influence of both treatments on acute inflammatory change was equivalent (p > 0.05).

CONCLUSION

Efficacy of Yisaipu® tapering treatment is comparable to the full-dose therapy for hip arthritis in AS patients. Both treatments maintain remission of hip arthritis after patients achieved low disease activity.