Tuberculosis of the hip

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.

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).

The Diagnostic and Prognostic Value of Synovial Fluid Analysis in Joint Diseases

Liquid biopsy is an emergent test method for the diagnosis and prognosis in the clinic. Joint fluid, also known as synovial fluid, contains a variety of bioactive constituents that can be selectively detected and further evaluated in a convenient fashion. Therefore, synovial fluid analysis functions as a specific form of liquid biopsy and plays a vital role in numerous joint diseases. In spite of the component analysis of aspirated synovial fluid beingconsidered as the gold standard for diagnosis of joint infections, biopsy of joint fluid benefits the initial diagnosis and long-term prognosis of degenerative, inflammatory, autoimmune, traumatic, congenital, and even neoplastic joint diseases. The convenience and accuracy for disease evaluation are significantly elevated as a result of the combination of synovial fluid analysis and other novel clinical technologies. In this review, we shed light on the latent role of synovial fluid in the diagnosis and prognosis of articular diseases and proposed future prospects for relevant research in this field.

Do Changes in Hemoglobin and C-Reactive Protein Levels in Patients With Hip Tuberculosis After Two Months of Treatment Predict Tubercle Bacilli Deletion?

Background and objective Tuberculosis (TB) of the hip refers to the hip infection caused by tubercle bacilli. Treatment for hip TB includes anti-TB medications, surgery to remove joint abscesses, and orthopedic surgery. It is necessary to conduct tests to confirm that the tubercle bacilli have been eradicated following the treatments. In this study, we aimed to assess the change in hemoglobin and C-reactive protein (CRP) serum levels in patients with hip TB before and two months after receiving specific treatments. We sought to determine whether they are significant tests for the treatment prognosis of hip TB. Methods We employed a prospective cohort design for this study. It was conducted at National Lung Hospital, Hanoi, and involved 24 hip TB patients with intra-articular abscesses who were treated at the center during the period from October 2016 to October 2021. Blood hemoglobin, CRP serum level, and abscesses on hip MRI were assessed before and two months after treatments. Hemoglobin was examined by spectrophotometry, and CRP serum was measured using the immunoturbidimetric method. Results Before treatments, the average hemoglobin level in the patients was 11.48 ± 1.85 g/dl; the average CRP serum level was 63.53 ± 36.47 mg/l. After two months of treatments, the average hemoglobin level increased significantly to 13.22 ± 1.36 g/dl, while the average CRP level reduced significantly to 12.55 ± 11.34 mg/l. However, five cases displayed abnormal findings. These five individuals continued to have intra-articular abscesses. Conclusion In individuals who reacted well to the therapy, blood hemoglobin and CRP serum levels improved. Blood hemoglobin and serum CRP assays can be utilized to monitor outcomes in hip TB therapy.

Treatment of Stage I-III Hip Joint Tuberculosis With Open Surgical Debridement and Hip Spica in Children: A Retrospective Study

BACKGROUND

This study aimed to evaluate the outcome of surgical debridement combined with postoperative hip spica immobilization in the treatment of hip joint tuberculosis in children.

METHODS

This retrospective study enrolled 87 children with stage I to III hip joint tuberculosis treated surgically at our hospital from January 2010 to January 2016. All patients considering hip tuberculosis routinely received a 4-week conservative treatment first, including rest, protected weight-bearing, and 4-drugs antitubercular chemotherapy. Surgical debridement was indicated when there was no relief after this conservative protocol. Patients were divided into 2 groups according to the duration of hip spica immobilization after operation: group A (hip spica for 4 wk, 39 patients) and group B (hip spica for 6 wk, 48 patients). All patients were recommended partial weight-bearing for 7 days and then followed the same hip joint exercises program when spica was removed. Postoperative radiographs, hip dislocation or subluxation, and modified Harris hip score (MHHS) were assessed. All patients were followed up at least 5 years.

RESULTS

There were 87 patients enrolled in our study, including 34 females and 53 males, with a mean age of 7.2±2.8 years old (range: 2 to 14 y). No significant difference was observed between these 2 groups in baseline data. In group A, the mean MHHS improved from 52.1±14.7 before surgery to 87.8±8.3 at the final follow-up ( P <0.000). In group B, there was also a significant difference between the preoperative MHHS (52.7±9.4) and the final MHHS (88.6±6.5) ( P <0.000). Although there was no significant difference between these 2 groups in the final MHHS ( P =0.593), there were also no significant differences between these 2 groups in wound healing delay (3 in group A and 6 in group B, P =0.705) and pathologic subluxation (3 in group A and 1 in group B, P =0.467). The only difference between group A (79.2±8.5) and group B (75.5±7.5) was the early functional outcome assessed by using MHHS after 1 month of hip joint exercises ( P =0.032).

CONCLUSIONS

Surgical debridement combined with antitubercular chemotherapy is an effective treatment for stage I to III hip tuberculosis in children when there is no improvement after conservative treatment. Prolonged hip spica immobilization may not reduce the risk of hip subluxation after open surgical debridement but could lead to a delay in early functional recovery. Time of spica immobilization should be individualized and based on the surgeon's evaluation and the patient's condition.

Anti-tuberculosis drug delivery for tuberculous bone defects

INTRODUCTION

Traditional therapy methods for treating tuberculous bone defects have several limitations. Furthermore, systemic toxicity and disease recurrence in tuberculosis (TB) have not been effectively addressed.

AREAS COVERED

This review is based on references from September 1998 to September 2021 and summarizes the classification and drug-loading methods of anti-TB drugs. The application of different types of biological scaffolds loaded with anti-TB drugs as a novel drug delivery strategy for tuberculous bone defects has been deeply analyzed. Furthermore, the limitations of the existing studies are summarized.

EXPERT OPINION

Loading anti-TB drugs into the scaffold through various drug-loading techniques can effectively improve the efficiency of anti-TB treatment and provide an effective means of treating tuberculous bone defects. This methodology also has good application prospects and provides directions for future research.

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.

Arthroscopic Ankle Arthrodesis for End-Stage Tuberculosis of the Ankle: A 2-Year Follow-Up

Surgical treatment for end-stage ankle joint tuberculosis (TB) has rarely been reported. This study followed cases treated by arthroscopic arthrodesis for ankle joint TB to evaluate its efficacy and safety in the clinic. Patients who underwent arthroscopic ankle arthrodesis for ankle joint TB between April 11, 2010, and December 31, 2016, were followed. Their diagnoses were confirmed by bacterial culture or pathological examination. During arthroscopy, tissue samples were first obtained to further confirm the diagnosis. Then the necrotic tissue, hyperplasia of synovial tissue, and exfoliated cartilage were removed. Ankle joint arthrodesis was performed if the area of articular cartilage damage was >2 cm². Continued nutritional support and standardized anti-TB drug treatment were given after surgery. Follow-up measurements included visual analogue scale score, American Orthopaedic Foot and Ankle Society score, erythrocyte sedimentation rate, and radiographic imaging. All 9 patients in this study, with an average age of 54 (range 37 to 68) years, were followed. The mean follow-up duration was 55.44 ± 31.15 (range 24 to 96) months. There were significant differences in the visual analogue scale scores, American Orthopaedic Foot and Ankle Society scores, and erythrocyte sedimentation rate between before treatment and 18 months postoperatively (p < .05). All patients (100%) showed union at 18 ± 4 weeks. Arthroscopic treatment for ankle joint TB has the advantages of minor trauma and low complications. It can be used to accurately obtain samples from specific areas of TB for further diagnosis. According to the degree of articular cartilage damage, the surgeon can determine whether to perform arthrodesis. Thorough debridement of necrotic tissue and residual articular cartilage on the fusion surface can improve the rate of ankle fusion.

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.

Total Hip Arthroplasty in 52 Active Advanced Tubercular Arthritic Hips

BACKGROUND

The role of total hip arthroplasty (THA) in healed tuberculosis (TB) of the hip has been reported with success in the past. However, the role and success of THA in active TB of the hip has remained controversial.

METHODS

We retrospectively evaluated a prospective study of 52 THAs done for active TB of the hip in 51 patients. The protocol includes 3-6 months of effective preoperative and 9-18 months postoperative anti-TB therapy. All THAs were performed by the same surgeon (author 1). The selection criteria excluded patients with poor immunity, HIV +ve patient, and presence of discharging sinus. The type of THA implant includes 12 cemented, 38 uncemented, and 2 hybrid fixations.

RESULTS

The mean follow-up was 10.5 years (2-29). Six patients were (6 THAs) lost to follow up after 4 years, including 2 deaths unrelated to TB or THA. There was no reactivation of TB. Mean Harris Hip Score improved from preop 31.77 (20-51) to postop 88 (72-100) in the last follow-up. Two patients had delayed wound healing up to 21 days postop with no evidence of subsequent episode till last follow-up. There was no case of dislocation, neurological complication in any patient. Seven THAs underwent revision for aseptic loosening unrelated to TB.

CONCLUSION

Single-stage THA is safe in active advanced tubercular arthritic hips with good immunity status under cover of effective anti-TB therapy using strict preop selection protocol.

Use of Ultra-Deep Sequencing in a Patient with Tuberculous Coxitis Shows Its Limitations in Extrapulmonary Tuberculosis Diagnostics: A Case Report

Unbiased metagenomic next-generation sequencing (mNGS) has been widely applied in clinical microbiology for infectious disease diagnostics. Some successful applications in central nervous system infections and respiratory tract infections have proved it to be a promising tool for pathogen detection. Here, mNGS was used to confirm the infectious etiology in a case of tuberculous coxitis, which is a common type of extrapulmonary tuberculosis (TB). A 77-year-old Asian male presented with hip pain and fever was diagnosed with smear- and culture-negative tuberculous coxitis based on the evidence of imaging and interferon-γ release assay. At the same time as the anti-TB therapy started, the patient underwent joint clearance surgery. Whole blood and synovial fluid sampled from surgery were kept for bacteriological confirmation using mNGS with high sequencing depth. However, only two paired-end reads from synovial fluid samples were identified as Mycobacterium tuberculosis. Before leaving hospital, the patient was still receiving anti-TB treatment and began to recover. Considering the obvious escalation of the cost and analysis time as the depth of sequencing increases, although we got a positive result here, the scarce number of reads obtained through ultra-deep sequencing indicates its limitations in extrapulmonary tuberculosis.

Total hip arthroplasty in the setting of tuberculosis infection of the hip: a systematic analysis of the current evidence

INTRODUCTION

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 due to concerns of disease reactivation. Over the past several decades, a number of authors have reported outcomes of THA for tuberculosis (TB) infections. However, there is marked heterogeneity in regard to disease activity, surgical approaches, and the use of chemoprophylaxis in these studies.

AREAS COVERED

The purpose of this review was to critically assess: 1) patient characteristics; 2) perioperative planning; 3) clinical outcomes; 4) radiographic outcomes; and 5) complications of THA in the setting of tuberculosis of the hip.

EXPERT OPINION

THA is an effective treatment for post-TB hip arthritis. There has been controversy regarding its safety during the past several decades, as it has been thought to increase the risk of disease reactivation. While studies thus far have shown generally favorable results, they have been limited by small sample sizes and their design as retrospective case series. Comparison of these studies reveals marked heterogeneity in the clinical management of this complex disease. However, synthesis of their findings demonstrates favorable outcomes and low rates of complication, including disease reactivation particularly when perioperative anti-tuberculosis therapy is instituted.

Arthroscopic management for early-stage tuberculosis of the ankle

Background

Due to atypical clinical presentation, wide use of antibiotics, and lack of specificity in diagnosis, diagnosis of tubercular (TB) infection in joints is increasingly difficult, and misdiagnosis is common. The use of arthroscopy for the diagnosis and treatment of early-stage ankle TB has rarely been reported. This case series intended to present the clinical outcomes of arthroscopic management for early-stage ankle TB.

Methods

Fifteen patients with chronic synovitis of the ankle and suspicious cause of early-stage ankle TB underwent arthroscopic treatment from April 1, 2010, to March 31, 2016. These cases all failed to confirm diagnosis of TB by ankle arthrocentesis. They included seven males and eight females with an average age of 37.5 (8 to 70) in the study. Among them, five cases had history of pulmonary tuberculosis, and six had history of trauma. The procedure included synovial membrane biopsy and debridement. The diagnosis was confirmed by pathologic examination and culture. The treatment was combined with systemic anti-tuberculous drugs. Follow-up measurements included VAS score, AOFAS score, ESR, CRP, and MRI.

Results

After arthroscopic management, 13 cases confirmed TB by pathologic examination and culture, and two cases still remained clinically suspected TB; the rate of confirmed case was 87%. The incision healed well in all cases, and no serious complications were observed. There were significant differences in VAS scores, AOFAS scores, ESR, and CRP between before and after treatment (P < 0.01). Joint swelling disappeared or was relieved after 2 months in most patients. Ankle swelling and pain in one patient was improved after changing anti-tuberculous drugs. MRI suggested that all patients had effusion in the articular cavity, accompanied by bone edema of the distal tibia and talus before the treatment. After the surgery, the effusion was significantly reduced, and the signal of bone edema almost disappeared. No recurrent TB was found during the follow-ups.

Conclusion

Arthroscopic management for early-stage ankle TB is minimally invasive, safe, and reliable. It can easily obtain samples from specific area of TB for further confirmation of the diagnosis, while the debridement can also assist in local disease control. For cases of highly suspicious joint TB, arthroscopic biopsy and debridement after transient anti-TB treatment is recommended.

Level of evidence

Level IV, therapeutic case series

Electronic supplementary material

The online version of this article (10.1186/s13018-018-1048-y) contains supplementary material, which is available to authorized users.

Total hip replacement in tuberculosis of hip: A systematic review

Total hip replacement (THR) in patients with tuberculous arthritis of the hip is controversial. The timing of surgery, type of prosthesis, reactivation of the disease, high complication rates and the long-term survival of the reconstruction are the major conc erns. There is little information regarding this concern in the literature. We conducted a systematic review of published studies on Total Hip Replacement in patients with Tuberculosis of the hip. A search of Pubmed and Google Scholar database articles published between January 2000 and July 2017 was performed. Thirteen articles were identified, comprising 226 patients. The mean follow-up was 5.48 years. Antituberculosis treatment was given for atleast 2 weeks pre-operatively and continued post-operatively for between six and 18 months after THR. Three patients had reactivation of infection. At the final follow-up, the mean Harris hip score was 89.98. Total Hip Replacement in tuberculosis of hip is safe and efficient way to save the joint function. The most important factors to achieve success include the accurate diagnosis, efficient pre- and postoperative anti-tuberculosis therapy, thorough debridement, two stage procedure for patients with sinus(es).

Osteoraticular Tuberculosis-Brief Review of Clinical Morphological and Therapeutic Profiles

Osteoarticular tuberculosis (OATB) is a rare form of tuberculosis (TB) whose incidence rose significantly nowadays especially in the underdeveloped countries. The main risk factors predisposing to this new challenge for the medical system are the Human Immunodeficiency Virus (HIV) epidemic, the migration from TB endemic areas and the development of drug and multidrug-resistant strains of Mycobacterium tuberculosis (Mt). The disease affects both genders and any age group although the distribution depending on gender is controversial and that depending on age has a bimodal pattern. In most cases the initial focus is elsewhere in the organism and the most frequent pathway of dissemination is lympho-haematogenous. The clinical picture includes local symptoms as pain, tenderness and limitation of motion, with some particularities depending on the segment of the osteoarticular system involved, sometimes accompanying systemic symptoms specific for TB and other specific clinical signs as cold abscesses and sinuses. The radiographic features are not specific, CT demonstrates abnormalities earlier than plain radiography and MRI is superior to plain radiographs in showing the extent of extraskeletal involvement. Both CT and MRI can be used in patient follow-up to evaluate responses to therapy. TBhas been reported in all bones of the body, the various sites including the spine (most often involved) and extraspinal sites (arthritis, osteomyelitis and tenosynovitis and bursitis). Two basic types of disease patterns could be present: the granular type (most often in adults) and the caseous exudative type (most often in children) one of which being predominant. The algorithm of diagnosis includes several steps of which detection of Mt is the gold standard. The actual treatment is primarily medical, consisting of antituberculosis chemotherapy (ATT), surgical interventions being warranted only for selected cases. It is essential that clinicians know and refresh their knowledge about manifestations of OATB.

Total Hip Arthroplasty Indicated for a Tuberculous Coxitis Complicating a Controlled Acquired Imunodefficiency Syndrom Condition: A Preliminary Report Concerning a Case

Introduction:

Total hip arthroplasty (THA) remains controversial in active tuberculosis (TB) infection because of the risks of septic loosening and reactivation of the infection. We present a rare case of THA in a patient positive for the human immunodeficiency virus (HIV) with active tuberculous coxitis. The aim of this work is to share our experience and our preliminary results.

Case Report:

The patient was a 53-year-old Black African woman, positive for the HIV, who was operated for implantation of a THA via the Hardinge approach indicated for a severe painful hip with restriction of joint movement and limp. A creamy-white liquid was noticed in the hip joint which was negative for urgent Gram-staining. The surgery was completed with the implantation of a hybrid THA. The post-operative period was uneventful, and she was put on antituberculous drugs following a positive histology result for TB, and to continue her antiretroviral drugs. She still has a satisfactory result for 3 years since her surgery.

Conclusion:

On condition that the patient is put simultaneously on triple antibiotics and antituberculous drugs, we propose that THA could be an option in patient presenting with the association of HIV infection and active tuberculous coxitis.

[Total hip replacement as a result of coxalgia: about 10 cases]

La coxalgie entraine des destructions ostéo-cartilagineuses de l'articulation de la hanche, ces lésions sont responsables de douleurs intenses provoquant des gènes fonctionnelles et des limitations dans la vie quotidienne. Leur traitement chirurgical est encore mal codifié. Notre objectif est de montrer à travers cette étude l'intérêt de l'arthroplastie totale de hanche associée à la chimiothérapie antituberculeuse pour l'amélioration de la qualité de vie des patients. Nous rapportons une étude rétrospective portant sur 10 cas de prothèses totales de hanche posées sur séquelles de coxalgie au service de traumatologie-orthopédie du centre hospitalier universitaire Rabat de 2002 à 2011. L’âge moyen de nos patients est de 38 ans. La découverte de la coxalgie s'est faite dans des circonstances différentes en fonction des patients. La voie d'abord que nous avons utilisé est exclusivement postéro-externe de Moore. Les prothèses posées ont toute été cimentées. Quatre patients ont nécessité la reconstruction du cotyle. La biopsie peropératoire est positive chez un patient, négative chez les neuf restants. Tous les patients ont été mis sous traitement antituberculeux. Aucune récidive n'a été notée après un recul minimal de 3 ans. Les résultats selon la cotation de Merle d'Aubigné sont jugés bons. En cas de destruction osseuse avancée avec retentissement fonctionnel très mal supporté chez le sujet d’âge mûr, l'arthroplastie totale demeure le traitement de choix des séquelles de coxalgie sous couverture systématique d'une chimiothérapie antituberculeuse efficace.

Two-stage total hip arthroplasty for patients with advanced active tuberculosis of the hip

Background

Treatment of advanced active tuberculosis (TB) of the hip is confronted with great challenges. Although one-stage total hip arthroplasty (THA) is considered as a safe procedure for most patients by some authors, there are still exceptions. The purpose of this paper was to investigate the feasibility and effectiveness of two-stage THA for selected patients with advanced active TB of the hip.

Methods

Nine consecutive patients with advanced active tuberculous arthritis of the hip were reviewed in this study. Out of these nine patients, the hips of five were destroyed extensively with difficulties of thorough debridement at one operation, and the hips of the other four were detected of sinus tracts. Nine patients received the two-stage total hip arthroplasty (THA) protocol and the perioperative antituberculous medication between January 2008 and December 2013. During the first stage, a debridement was carried out after at least 2 weeks of antituberculous chemotherapy to remove abscesses and infected and necrotic tissues as thoroughly as possible, followed by antituberculous chemotherapy for a minimum of 3 months (average 4.2 months). During the second stage, hip prosthesis was implanted if the erythrocyte sedimentation rate (ESR) and the C-reactive protein (CRP) were normal and the wound was well healed. Antituberculous chemotherapy was continued for 6–9 months postoperatively to constitute a total duration of a minimum of 12 months after the first operation. The patients were then evaluated based on the reactivation of infection, the Harris hip score system, X-ray, ESR, and CRP.

Results

The average follow-up was 40 months (range, 18–72 months). No reactivation of TB or superimposed infection was observed in all patients. The ESR and CRP returned to the normal level with no liver injury. The average Harris hip score was increased from 35 (range, 15–55) preoperatively to 91.5 (range, 83–97) at the final follow-up. The X-ray film showed no prosthesis shift or loosening.

Conclusions

Two-stage THA is an alternative treatment option for patients with advanced active tuberculosis of the hip under some difficult conditions. The hip with sinus tracts or destroyed extensively with difficulties of thorough debridement at one operation may be regarded as indications.

Functional improvement after hip arthroscopy in cases of active paediatric hip joint tuberculosis: a retrospective comparative study vis-à-vis conservative management

PURPOSE

Tuberculosis of the hip joint is a significant cause of preventable disability, especially in children. The aim of our study was to evaluate the functional results of hip arthroscopy done in a cohort of patients with hip joint tuberculosis and to compare them with the outcome of conservatively managed cases.

METHODS

This was a retrospective cohort study in which we evaluated the records of 22 hip arthroscopies performed in known cases of tuberculosis of the hip joint in children less than 12 years of age. A note of the demographic and clinical parameters like age, duration of symptoms, stage of the disease, time period of follow-up, any complications during surgery, and pre- and post-operative modified Harris hip score (MHHS) was made in all cases. We compared the results with an age-matched cohort of 44 children with hip joint tuberculosis who were treated non-operatively with anti-tuberculosis therapy and traction in the same tertiary care institute.

RESULTS

The arthroscopic findings in our series included synovitis, chondral erosions of the femoral head and/or acetabulum, pannus formation over the femoral head and/or acetabulum, and labral tears. The various arthroscopic procedures which were done included joint lavage, synovectomy, labral debridement and cheilectomy. The mean follow-up was 45 months, with the minimum being 36 months. There was a statistically significant change in the mean MHHS after hip arthroscopic procedures (p < 0.001); the difference in the mean post- and pre-operative MHHS was independent of age, stage or duration of follow-up. There was a statistically significant difference (p < 0.05) between the magnitude of improvement in MHHS after hip arthroscopy and that after conservative management.

CONCLUSIONS

Arthroscopy of the hip joint in children in cases of tuberculosis can serve as an emerging therapeutic modality. It is an effective and safe minimally invasive procedure, and helps in improving the functional outcome in early disease.

[Osteo articular tuberculosis (Pott disease excluded): about 120 cases in Abidjan]

Introduction

La tuberculose ostéoarticulaire (TOA) représente 2 à 5% de l'ensemble des tuberculoses. Elle demeure d'actualité surtout dans les pays à forte endémicité tuberculeuse. L'objectif était de déterminer la prévalence, les aspects topographiques, radiologiques de la TOA en milieu hospitalier ivoirien.

Méthodes

Les auteurs rapportent une expérience de 11 ans, à travers une étude rétrospective de 120 dossiers de patients atteints de la tuberculose ostéoarticulaire (le mal de Pott est exclu de cette étude). N'ont pas été inclus dans l’étude les dossiers ne comportant pas d'imagerie.

Résultats

L'atteinte extra vertébrale représentait 09,2% de la tuberculose ostéoarticulaire. Il s'agissait de 54 hommes et 66 femmes, l’âge moyen était de 43,13 ans. On notait 123 cas d'ostéoarthrites, et 8 cas d'ostéites des os plats. L'atteinte des membres inférieurs prédominait dans 91,87% des cas. La hanche était la première localisation (45,04%), suivie du genou (25,19%). Les atteintes étaient multifocales dans 20% des cas. L'atteinte osseuse était associée à une tuberculose pulmonaire dans 05,83% des cas. Des localisations inhabituelles ont été rapportées: poignet (n = 2), branches ischiopubiennes (n = 4), atteinte sternoclaviculaire (n = 4), médiopieds (n = 2). Les lésions radiologiques étaient avancées (stades III et IV) dans 55,73% des cas. A la TDM, la prévalence des abcès était de 77%. Un geste chirurgical a été réalisé sur 16 articulations (2 épaules, 13 genoux, une cheville).

Conclusion

La TOA des membres est peu fréquente contrairement à l'atteinte vertébrale. La hanche est la principale localisation. Le retard au diagnostic explique l’étendue des lésions anatomoradiologiques.

Computed tomography detection of clinically unsuspected skeletal tuberculosis

OBJECTIVE

To report the frequency of clinically unsuspected axial skeletal tuberculosis (STB) and findings on computed tomography (CT).

MATERIALS AND METHODS

An evaluation of CT chest, abdomen, and pelvis of patients with tuberculosis was done. Bone window images were evaluated for skeletal involvement.

RESULTS

Of the 726 CT studies, 34 (4.7%) patients had skeletal involvement. Thoracic spine was the most commonly affected site with involvement of body in 58% cases. Intervertebral disc involvement, soft tissue abscess, and epidural extension were identified in 83%, 53%, and 39% of cases, respectively.

CONCLUSION

Evaluation of bone window on CT can detect axial STB.

Tuberculosis of hip: A current concept review

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.

Case report on the recurrence of tuberculosis of hip after 40 years

Tuberculosis of joints is relatively rare condition and is associated with varied degree of immobility as well as other limitations. Tuberculosis of hip joint results in a remarkable decline in the living standard of the patients since hip joint has a wide range of function in daily movements apart from being the pivotal weight bearing joint in human body. The degeneration of hip joint culminates into long term morbidity for the patient. In this case report we present a patient who had suffered from the tuberculosis of hip joint 40 years before and had received the standard anti-tuberculosis chemotherapeutic regimen with isoniazid, rifampicin, pyrazinamide and ethambutol. After treatment, the patient had some degree of relief from the pain however the movement of the hip joint was restricted; the restriction increasing progressively since. On diagnostic testing he was found to have a recurrence of tuberculosis along with the old scar tissue left by the primary condition. The patient was assessed thoroughly after which total hip replacement surgery was performed along with the adhesiolysis. The patient made a remarkable recovery after the surgery with a considerable increased range of movement in his hip joint.

Initial experiences with a new MRI scoring system for differentiating advanced femoral osteonecrosis from tubercular arthritis

The purpose of this study was to formulate a magnetic resonance imaging-based scoring system for differentiating tuberculous arthritis from advanced osteonecrosis of the femoral head. Magnetic resonance imaging findings in 18 hips with tuberculous arthritis and 36 hips with advanced osteonecrosis of the femoral head were reviewed retrospectively. Confirmation of tuberculous arthritis was based on enzyme-linked immunosorbent assay and/or synovial biopsy. Osteonecrosis was confirmed either by histopathology or eventual radiographic evidence on follow-up. The findings were analyzed with an emphasis on the changes in femoral head marrow, joint cavity, synovium, acetabulum, and contrast enhancement patterns. A score of 2 was assigned for the presence of each of the following: T2 hyperintensity of the femoral head, synovial hypertrophy, articular cartilage erosion, unilateral involvement of the femoral head, acetabular edema/sclerosis, and enhancement of the involved head. A score of 1 was assigned for each of the following: joint effusion, edema of adjacent marrow, and enhancement of adjacent soft tissue. A cutoff value of 10 of 15 points was considered to be positive for tuberculous arthritis. Sixteen of 18 cases of tuberculous arthritis were correctly identifiable on the basis of this scoring system. The 2 remaining cases had a score of 9. No case of osteonecrosis of the femoral head scored more than 9. A score of 10 for a positive diagnosis of tuberculous arthritis had a sensitivity of 88.89% and specificity of 100%. Positive and negative predictive values were 1 and 0.94, respectively. Statistical significance for each of the parameters and the entire model was established with logistic regression analysis. This new scoring system is effective in solving the imaging dilemma pertinent to endemic regions.

Bilateral pathological subluxation of hips secondary to tuberculosis in an adult: a rare presentation

Clinical descriptions of tuberculosis date back to antiquity. Extra-pulmonary involvement is noted in approximately 14% of patients, with 1% to 8% having osseous disease. In literature, some cases of bilateral traumatic dislocations have been described, but reports on bilateral pathological subluxations or dislocations of hip joints, that too in adults, are extremely rare. Tuberculosis can present in myriad ways and it can mimic any disease. The sole purpose of writing this article was to report one of the extremely rare presentations of skeletal tuberculosis.

Total hip replacement for patients with active tuberculosis of the hip: a systematic review and pooled analysis

The timing of total hip replacement (THR) in patients with active tuberculosis (TB) of the hip is controversial, because of the potential risk of reactivation of infection. There is little information about the outcome of THR in these patients. We conducted a systematic review of published studies that evaluated the outcome of THR in patients with active TB of the hip. A review of multiple databases referenced articles published between 1950 and 2012. A total of six articles were identified, comprising 65 patients. TB was confirmed histologically in all patients. The mean follow-up was 53.2 months (24 to 108). Antituberculosis treatment continued post-operatively for between six and 15 months, after debridement and THR. One non-compliant patient had reactivation of infection. At the final follow-up the mean Harris hip score was 91.7 (56 to 98). We conclude that THR in patients with active TB of the hip is a safe procedure, providing symptomatic relief and functional improvement if undertaken in association with extensive debridement and appropriate antituberculosis treatment.

Tuberculosis of hip in children: A retrospective analysis

BACKGROUND

Tuberculosis (TB) of hip constitutes nearly 15% of all cases of osteoarticular tuberculosis. We report a retrospective study carried out on 43 children with hip TB.

MATERIALS AND METHODS

Forty-three children of TB hip treated between 1971 and 2000 were analysed. Twenty-four children of the early series were treated with streptomycin (S), isoniazid (H) and PAS (Pa) for 18 months (3HPaS, 15 HPa), while 19 children in the later series were treated with isoniazid (H), rifampicin (R) and ethambutol (E) or pyrazinamide (Z) for 12 months [(12 RHE(Z)]. Five out of 18 children with radiologically normal appearing type hip TB were treated with chemotherapy alone and 38 children were subjected to surgery; simple synovectomy alone in 31 hips, joint debridement in six hips, and proximal femoral varisation osteotomy in one. After surgery hips were immobilized in cast for one to three months according to the severity of the disease and patients pain tolerance, and then were mobilized under leg traction in bed gradually till pain subsided completely.

RESULTS

TB of hip healed with minimum sequelae in all children. In 18 Type one hip TB, normal hip (synovial form) anatomy was maintained, and in 25 patients with advanced lesions some defect in the femoral head and acetabulum was noticed, though painless good hip motion was maintained. Excellent to good results were obtained in 31 children (73.1%), fair in eight (18.6%), and poor in four (9.3%). In four patients with poor results, there was some residual morphological defect in the hip. None developed ankylosis of hip.

CONCLUSION

We achieved good outcome with minimum sequelae in this series. The management goal should be aimed not only to heal the disease but also to maintain a painless mobile hip and anatomical cephalocotyloid relationship until maturity, and retard the development of secondary osteoarthritis.

Imaging features of extraaxial musculoskeletal tuberculosis

Tuberculosis (TB) continues to be a public health problem in both developing and industrialized countries. TB can involve pulmonary as well as extrapulmonary sites. The musculoskeletal system is involved in 1–3% of patients with tuberculosis. Although musculoskeletal TB has become uncommon in the Western world, it remains a huge problem in Asia, Africa, and many developing countries. Tuberculous spondylitis is the most common form of musculoskeletal TB and accounts for approximately 50% of cases. Extraspinal musculoskeletal TB shows a predilection for large joints (hip and knee) and para-articular areas; isolated soft tissue TB is extremely rare. Early diagnosis and prompt treatment are mandatory to prevent serious destruction of joints and skeletal deformity. However, due to the nonspecific and often indolent clinical presentation, the diagnosis may be delayed. Radiological assessment is often the first step in the diagnostic workup of patients with musculoskeletal TB and further investigations are decided by the findings on radiography. Both the radiologist and the clinician should be aware of the possibility of this diagnosis. In this manuscript we review the imaging features of extraspinal bone, joint, and soft tissue TB.

Cementless total hip arthroplasty for the management of tuberculosis coxitis

INTRODUCTION

Tuberculosis arthritis of the hip is a crippling disease and there is need for an effective and acceptable treatment for the hips with bone destruction. The aim of this report was to evaluate the efficacy of the diagnostic method for hip tuberculosis and clinical results of the patients to clarify the question of whether a total hip arthroplasty (THA) should be attempted on a patient with a current or previous infection.

MATERIALS AND METHODS

Nine patients with active tuberculosis of the hip, treated by cementless THA, were analyzed retrospectively. The mean age of the patients at diagnosis was 43.4 years (range 22-72 years). Laboratory tests of all the patients revealed high erthrocyte sedimentation rates (ESR) and C-reactive proteins. Plain radiographs showed bone destruction with joint space narrowing in all patients. Magnetic resonance imaging (MRI) scans showed fluid within the joint in five patients. Two patients had associated pulmonary tuberculosis. To confirm the clinico-radiological diagnosis, an open biopsy was performed for histopathological examinations of all the hips. Tuberculosis of the hips was treated with primary cementless THA, followed by postoperative antituberculous medication for 1 year. The inflamed soft tissues and the destroyed bones were completely resected and curetted out at the time of operation.

RESULTS

At the final evaluation, the mean Harris Hip Score improved to 94.8 (range 90-98; P = 0.003). ESR became normal, less than 15 mm/h, with a mean time of 4 months (range 2-9 months). The C-reactive protein was normal, less than 0.8 mg/dl, after a mean time of 3 months (range 1-7 months). With an average follow-up of 5.6 years (range 2-8 years), no reactivation of tuberculosis infection was found in each patient. All of the femoral stems and acetabular cups were radiologically stable and demonstrated signs of bone ingrowth at the final follow-up. All histopathologic examinations showed granulomatous lesions including epitheloid histiocytes surrounded by lymphocytes.

CONCLUSIONS

Cementless THA can be safely performed in advanced tuberculosis of the hip for providing symptomatic relief and functional improvement of the hips. Complete curettage and resection of the infected tissue and postoperative antituberculous chemotherapy with a minimum of 1-year duration are very important in preventing reactivations.

Total hip arthroplasty in patients with active tuberculosis of the hip with advanced arthritis

Osteoarticular tuberculosis (TB) in the hip and other joints is increasing and patients in developing countries commonly present with advanced joint destruction. We asked whether TB is reactivated after THA in these patients. We retrospectively reviewed 12 patients with an average age of 45 years who had advanced stages of hip destruction secondary to mycobacterium TB and who were treated with primary THA and prescribed perioperative antituberculous medication for 12 to 18 months postoperatively. Diagnosis in all these patients was confirmed by histopathology and culture. The minimum followup was 25 months (average, 41 months; range, 25-58 months). We observed no reactivation of TB in 11 patients who had Harris hip scores ranging from 86 to 97. One patient who postoperatively did not comply with the antituberculous chemotherapy had reactivation and superimposed infection through a nonhealing sinus tract; that patient underwent component removal and resection arthroplasty. When the infected tissue can be débrided and adequate antituberculous therapy is instituted the outcome of joint arthroplasty may not be adversely affected. THA in the tuberculous hip has a low risk of reactivation and produces good functional results.

LEVEL OF EVIDENCE

Level IV, therapeutic case series (no, or historical control group). See the Guidelines for Authors for a complete description of levels of evidence.

Chronic slowly progressive monoarthritis tuberculosis of the hip without systemic symptoms mimicking osteoarthritis: a case report

The authors report and discuss the clinical and radiological features of a immunocompetent patient with chronic progressive monoarthritis tuberculosis of the hip without systemic symptoms such as fever, and weight loss presenting as caseating abscess and severe destruction of the hip joint, treated with resection arthroplasty.

Total hip arthroplasty for active tuberculosis of the hip

Total hip arthroplasty (THA) has been used as a successful form of treatment in patients with long-standing tuberculosis, but it is unclear whether THA should be performed in patients with current infection. We performed THA in six patients with advanced active tuberculosis of the hip from 2002 to 2006. Tuberculosis was confirmed in all cases by histological examination. All patients were treated with antituberculous medications for at least two weeks followed by thorough debridement and THA. Antituberculous medications were administered postoperatively for at least 12 months. The duration of postoperative follow-up was an average of 49 months. No reactivation of the infection was detected in our series. Using the Harris hip score system, five of the patients were classified as excellent and one as good. THA in advanced active tuberculosis of the hip is a safe procedure providing symptomatic relief and functional improvement. Thorough debridement of infected tissues and postoperative antituberculous therapy are the keys to lowering the potential risk of reactivation of tuberculosis.

Chronic slowly progressive monoarthritis tuberculosis of the hip without systemic symptoms mimicking osteoarthritis: a case report

The authors report and discuss the clinical and radiological features of a immunocompetent patient with chronic progressive monoarthritis tuberculosis of the hip without systemic symptoms such as fever, and weight loss presenting as caseating abscess and severe destruction of the hip joint, treated with resection arthroplasty.

[Tuberculosis of the hip]

In Hungary about 1900-2500 new patients suffering from tuberculosis have been registered yearly in the last few years. In 2000 the incidence was 36/100,000, which decreased to 18.8/100,000 by the year 2006. Extrapulmonary, skeletal forms are uncommon and develop in a slow way, therefore the specific diagnostic steps are not part of the daily routine orthopedic examination. To provide appropriate diagnosis and successful treatment, the cooperative work of many faculties is essential. Authors report a case of a 19-year-old male patient with hip complaints in the last two years. X-ray, CT and MRI examinations proved a progressive pattern of destruction of the hip joint. Diagnostic steps and failures, also the surgical therapeutic solution of active hip tuberculosis, have been presented.

The comparison of pyrosequencing molecular Gram stain, culture, and conventional Gram stain for diagnosing orthopaedic infections

We have developed a combined real-time PCR and pyrosequencing assay that successfully differentiated the vast majority of gram-positive and gram-negative bacteria when bacterial isolates were tested. The purpose of this study was to evaluate this assay on clinical specimens obtained from orthopedic surgeries, and to prospectively compare the results of "molecular Gram stain" with culture and conventional direct Gram stain. Forty-five surgical specimens were obtained from patients who underwent orthopedic surgery procedures. The DNA was extracted and a set of broad-range PCR primers that targeted a part of the 16S rDNA gene was used for pan-bacterial PCR. The amplicons were submitted for pyrosequencing and the resulting molecular Gram stain characteristics were recorded. Culture and direct Gram staining were performed using standard methods for all cases. Surgical specimens were reviewed histologically for all cases that had a discrepancy between culture and molecular results. There was an 86.7% (39/45) agreement between the traditional and molecular methods. In 12/14 (85.7%) culture-proven cases of bacterial infection, molecular Gram stain characteristics were in agreement with the culture results, while the conventional Gram stain result was in agreement only for five cases (35.7%). In the 31 culture negative cases, 27 cases were also PCR negative, whereas 4 were PCR positive. Three of these were characterized as gram negative and one as gram positive by this molecular method. Molecular determination of the Gram stain characteristics of bacteria that cause orthopedic infections may be achieved, in most instances, by this method. Further studies are necessary to understand the clinical importance of PCR-positive/culture-negative results.

Tuberculosis of the greater trochanter. Report of four cases

OBJECTIVE

To present four cases of tuberculosis of the greater trochanter.

CASE PRESENTATION AND INTERVENTION

The four cases (3 females and 1 male), aged 45-70 years, presented with mechanical pain in the trochanteric area associated with progressive swelling in the 3 female patients in whom mobility was also restricted. X-ray revealed a mass in 2 females; CT scan and MRI exhibited an abscess in the 3 females. Histological and bacteriological examinations showed Mycobacterium bovis in the 3 females and M. tuberculosis in the male. In the females, tritherapy and surgery were performed, while in the male quadritherapy and surgery. All the patients recovered and were followed up for 4-9 years.

CONCLUSION

These cases show that both chemotherapy and surgery must be synergic if tuberculosis is diagnosed and an abscess is confirmed by imaging.