Total hip replacement for arthritis following tuberculosis of hip

A Case Report on Advanced Hip Tuberculosis: Outcomes of Combined Surgical and Rehabilitative Intervention

Although rare, musculoskeletal involvement of tuberculosis (TB) sustains this disease as a global health problem. Hip TB presents some unique challenges to its diagnosis and cure because of its specific anatomical and biomechanical properties. Herein, we would like to highlight an integrated approach in the surgical intervention and rehabilitation towards the management of an advanced symptom-bearing 25-year-old female hip TB patient. She had taken treatment for tuberculosis, but even then, her right hip was painful, and movements were severely restricted. Imaging revealed severe destruction of the hip joint; a bone biopsy confirmed tuberculous osteomyelitis of the hip joint. Total hip replacement (THR) revealed the severe destruction of the hip joint by imaging and was found positive by bone biopsy for tuberculous osteomyelitis. The rehabilitation after the surgery consisted of measures for pain control, mobility training exercises, muscle strengthening, and balance training exercises. After six weeks of THR, the patient showed considerable improvement in pain level, flexibility, muscle strength, and functional status during assessments. What is highlighted is the complexity that lies in the management of TB of the hip, which requires the multidisciplinary approach that the case above calls for. In the future, more sophisticated diagnostics and newer therapies should be patient-reported and outcome-oriented. Larger multicenter studies directed to the various populations would be beneficial in this direction. The small size of the study, its single-center dimension, and the short follow-up limited broader applicability and long-term insights.

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 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.

Tuberculous arthritis of native joints - a systematic review and European Bone and Joint Infection Society workgroup report

Introduction: The aim of this systematic review was to assess the existing published data on the diagnosis and management of tuberculosis (TB) arthritis involving native joints in adults aged 18 years and older. Methods: This study was performed in accordance with the guidelines provided in the Preferred Reporting Items for Systematic reviews and Meta-Analysis extension for Scoping Reviews (PRISMA-ScR). Results: The systematic review of the literature yielded 20 data sources involving 573 patients from nine countries. There was considerable variation amongst the studies in terms of the approach to diagnosis and management. The diagnosis was mostly made by microbiological tissue culture. Medical management involved a median of 12 months of anti-tubercular treatment (interquartile range, IQR, of 8-16; range of 4-18 months). The duration of preoperative treatment ranged from 2 to 12 weeks. Surgery was performed on 87 % of patients and varied from arthroscopic debridement to complete synovectomies combined with total joint arthroplasty. The mean follow-up time of all studies was 26 months (range of 3-112 months). Recurrence rates were reported in most studies, with an overall average recurrence rate of approximately 7.4 % (35 of 475 cases). Conclusions: The current literature on TB arthritis highlights the need for the establishment of standardized guidelines for the confirmation of the diagnosis. Further research is needed to define the optimal approach to medical and surgical treatment. The role of early debridement in active TB arthritis needs to be explored further. Specifically, comparative studies are required to address questions around the use of medical treatment alone vs. in combination with surgical intervention.

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).

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.

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.

Extraspinal articular tuberculosis: An 11-year retrospective study of demographic features and clinical outcomes in East London

OBJECTIVES

To describe demographic features, clinical outcomes and diagnostic delay amongst patients with extra-spinal articular tuberculosis (TB) in a low-incidence setting.

METHODS

Cases of TB treated at our institution between 2004 and 2014 were identified via the London TB register (LTBR). Demographic features of extra-spinal articular TB cases were compared to controls with TB at all other sites. For articular cases (excluding individuals <16 years or with spinal TB without peripheral joint involvement) clinical data were retrospectively collected.

RESULTS

6,146 TB patients were identified over the study period; 146 (2.4%) cases had extra-spinal articular infection. There was no difference in median age between extra-spinal articular TB cases and controls with TB at other sites (31 vs 32 years, p = 0.57). Articular cases were more likely to be male (70.6% vs 59.5%, p = 0.007), Bangladeshi (28.7% vs 18.0%) or Pakistani (24.0% vs 16.1%) and were less likely to be Black-African (9.5% vs 19.8%) (p < 0.001). 93 cases were included in the case series; 85 (88.5%) were migrants and 83 (89.2%) were South Asian. Knee and elbow joints were affected in 22 (23.7%) and 18 (19.4%) cases respectively. The median durations of pre-healthcare and healthcare associated delay were 16 and 6 weeks respectively. Where mycobacterial culture was performed, 57/75 (76%) were positive for Mycobacterium tuberculosis. 86 (92.5%) cases received standard quadruple therapy for a median of 6 months (IQR 6-9). Recurrence of TB infection occurred in 4 (4.3%) cases and there were no TB related deaths. Seven (7.6%) cases required surgical intervention.

CONCLUSIONS

Extra-spinal articular TB more commonly affected men and people of South Asian ethnicity. Significant diagnostic delays were identified, including avoidable healthcare-associated delays.

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.

Hip Surgery in Quiescent or Active Tubercular Hip Arthritis; Is Reactivation Risk Really a Matter

About 15 % of all musculoskeletal tuberculosis (TB) have hip involvement. Early anti-tubercular drug therapy and other conservative treatment including short-term traction and mobilization programs could prevent hip joint destruction. Reactivation of TB accounts for a significant of active TB incidence, especially in the developed countries with a low TB prevalence. The risk of TB activation for population with the latent form of disease is about 5-10%. According to the existing literature surgery in tubercular hip arthritis would be safe once sufficient debridement and precise anti tubercular chemotherapy has been done.

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).

Proximal Femoral Fracture in Hip Arthrodesis Treated with Double Reconstruction Plates

We present a rare clinical case of a 90-year-old female who sustained a proximal femoral neck fracture following long-standing hip arthrodesis. Since the fracture occurred relatively proximally and involved the pelvis, double-plate fixation was chosen to achieve rigid fixation. The reconstruction plate was placed at the posterior and anterior columns individually through single vertical incision. She was treated successfully, and she attained preinjury activity level. Proximal femoral fractures in arthrodesed hips need to be recognized as a fracture between the pelvis and femur. Rotational stress from the trunk and lower extremity requires rigid fixation to minimize the increase of displacement and the risk for nonunion.

Tuberculous periprosthetic infection precipitated by infliximab therapy

Biological therapy with TNF-α inhibitors have been increasingly used in the treatment of inflammatory arthritis. Systemic tuberculosis infections are often known to occur following treatment with these biological agents. However, no case of periprosthetic tuberculous infection of the hip following this therapy has been reported. We report a case of a 45-year-old man who developed periprosthetic tuberculous infection soon after infliximab injection. We also discuss the need of pretreatment awareness, high index of suspicion, early diagnosis and management of such case.