Insidious destruction of the hip by Mycobacterium tuberculosis and why early diagnosis is critical

Tuberculous Septic Arthritis of the Hip Following the Incision and Drainage of a Groin Abscess: A Case Report

Tuberculosis of the hip is a relatively rare type of septic arthritis that is seldom seen in the developed world today. While pyogenic septic arthritis may present with clear features that help in early diagnosis and treatment, many of these features are absent or overlap significantly with tuberculous arthritis, making the diagnosis a clinical challenge. Here, we present a case of tuberculous septic arthritis seen in our clinic following the surgical incision and drainage of a groin abscess with minimal hip symptoms. We discuss the therapeutic approach for the patient and briefly review other reported cases of tuberculous septic arthritis in the literature.

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.

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.

Use of Polymerase Chain Reaction to Diagnose Tuberculous Arthritis From Joint Tissues and Synovial Fluid

Context.—Tuberculosis of the joints and bones is a significant worldwide problem, often leading to joint and bone destruction. The diagnosis of this disease manifestation is difficult.

Objective.—To assess the role of conventional diagnostics compared to polymerase chain reaction applied to samples obtained at arthroscopy.

Design.—This was an open observational study that was blinded to the microbiologist, histopathologist, and molecular biologist responsible for assessing the main outcome measures.

Patients.—Seven patients (8 samples) with joint and bone tuberculosis and 14 patients (16 samples) with nontuberculous joint and bone disease.

Intervention.—Arthroscopic examination and tissue sample collection.

Main Outcome Measures.—Mycobacterium tuberculosis staining, culture, and histopathologic assessment of caseating granulomas vs polymerase chain reaction.

Results.—Polymerase chain reaction was positive in all cases of true tuberculosis and falsely identified 2 samples as positive, both however, in patients who had lung tuberculosis in the past.

Conclusions.—Conventional bacteriological methods for demonstration of M tuberculosis are not very sensitive and can be time-consuming. Polymerase chain reaction of arthroscopically obtained joint tissue biopsies appears promising in the early diagnosis of tuberculous arthritis.

Tuberculosis of the hip

Tuberculosis of the hip constitutes approximately 15% of all cases of osteoarticular tuberculosis. The common age of presentation is in the second and third decades. In Stages II and III of the disease, the radiologic features are very obvious and diagnostic, and almost always predict the final clinical outcome. A progressive pattern of destruction of the hip occurs in patients who are not treated. Treatment must be instituted early with an aim of salvaging the hip. Treatment comprised of drug therapy, traction, and supervised mobilization produces good results in patients with early stages of the disease. Patients who do not have a favorable clinical response to conservative treatment should have surgery before the hip is destroyed. In the eastern hemisphere, patients prefer a painless but mobile joint, for satisfying the customary needs of squatting, sitting cross-legged, and kneeling. Therefore, excision arthroplasty produces satisfactory results as compared with hip arthrodesis. Total hip arthroplasty should be considered only after a safe period of absolute disease quiescence.