Orthopedics - Oleksa A.P. 2006

Bone and Joint Tuberculosis
Tuberculosis of the Hip Joint

In terms of incidence, tuberculous coxitis ranks second among Other forms of Osteoarticular Tuberculosis. Primary osteitis is predominantly localized in the acetabulum, and less frequently in the femoral HEAD and Neck. If left untreated, tuberculous coxitis follows a classic clinical course. It begins with symptoms of tuberculous intoxication (loss of appetite, general malaise, and evening low-grade fever). The patient starts favoring the affected leg, children stop running, and pain appears, radiating to the sacrum, the lower third of the thigh, or the knee. Upon examination, the primary finding is typically the loss of passive hyperextension of the hip, followed over time by restricted abduction and rotational movements. Gradually, the ERYTHROCYTE SEDIMENTATION RATE (ESR) and lymphocyte count increase, and tuberculin Skin tests may yield positive results.

Following the rupture of the focus into the joint cavity, the arthritic phase manifests with severe pain, protective flexion-adduction contracture of the hip, marked restriction of movement, and inability to walk. An inflammatory process develops across all joint structures, resulting in tuberculous coxitis. During this period, cold abscesses and hip subluxations sometimes appear, accompanied by a positive Alexandrov's sign—an increased thickness of the skin fold on the affected limb. In the resolution phase, The activity of the process subsides, and all clinical signs gradually diminish. Reparative processes take precedence, leading to arthrogrypoic contracture, or—once the articular Cartilage and femoral head are destroyed—to fibrous and subsequently bony ankylosis in a malposition of the limb. Patients become disabled due to functional shortening of the limb, which may comprise all types of shortening if the condition originated in childhood.

The mainstay in diagnosing tuberculous coxitis is X-ray Examination (Fig. 386). In the pre-arthritic phase, computed tomography (CT) or Magnetic Resonance imaging (MRI) can detect the smallest subchondral and intraosseous foci, as well as Osteoporosis. Gross destructive changes, particularly in the arthritic phase, are clearly visible on standard plain radiographs.

Treatment. Regardless of the phase of the tuberculous process, the patient is first immobilized with a hip spica cast in a functionally advantageous position of the limb. The cast provides rest and exerts a favorable effect on the inflammatory process, prevents The Development of contractures in the Cytology/cytology/16.html">Early stages of the disease, and maintains the limb in a functionally advantageous position—especially in the arthritic and post-arthritic phases, when joint destruction leads to ankylosis. Patients are prescribed strict bed rest, antibacterial therapy, and general strengthening treatment. If a distinct subchondral focus fails to respond to Chemotherapy, early radical necrectomy is performed, which prevents joint involvement, shortens treatment duration, and leads to recovery. Advanced cases of tuberculous coxitis are currently rare; consequently, abscess necrectomy and other open surgeries are rarely performed.

In the presence of destructive changes within the joint, joint resection is performed along with the removal of all necrotic foci to achieve ankylosis in a functionally advantageous position of the limb, maintained either in a plaster cast or an Ilizarov apparatus.

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Fig. 386. Radiograph of tuberculous coxitis.

Surgical technique. Under endotracheal anesthesia, the Joint Capsule is exposed via the Smith-Petersen approach. Pus is aspirated using a puncture needle, and the joint is lavaged with a 1:5000 furacilin solution. Next, a T-shaped incision is made in the joint capsule, and its cavity is dried. The proximal end of the Femur is dislocated with the aid of Kornev's osteotome, which is used to transect the ligament of the head of the femur (ligamentum teres). Often, the destructive femoral head fractures during dislocation, in which case its remnants are removed piecemeal. The condition of the acetabulum is assessed and debrided with an osteotome within healthy bone limits. Necrotic masses are then removed from the Base of the head, and the end of the femoral neck is shaped to match the contours of the acetabulum. The joint capsule is completely excised, and the surgical wound is thoroughly lavaged and dried (toilet of the wound). The femoral head or neck is reduced into the acetabulum, and the leg is positioned in a functionally advantageous posture. A streptomycin solution is administered into the acetabular region. Occasionally, the joint is stabilized percutaneously with Kirschner wires inserted from outside the surgical wound.

The wound is drained using a nipple tube and closed in layers. A hip spica cast is applied, extending down the thigh of the healthy leg. The streptomycin and gentamicin solution is administered through the tube for two to three days, after which the tube is removed. The wires are extracted after three weeks. The cast on the healthy thigh is removed after 8–10 weeks, and the patient is allowed to walk on crutches. To prevent knee contracture, the cast is trimmed above the knee level after another two weeks.

Throughout this period, the patient receives anti-tuberculosis medications and a well-balanced, vitamin-enriched diet. The plaster cast is removed once bony ankylosis of the hip joint has formed.

Patients sometimes present with post-tuberculous ankylosis of the hip joint in a functionally unfavorable position or with anatomical shortening of the limb. In such cases, intertrochanteric or subtrochanteric osteotomy is performed, occasionally combined with myotomy of the adductor Muscles, to bring the limb into a functionally advantageous position.

Surgical technique. The operation is performed under anesthesia. Soft Tissues are incised linearly in layers along the lateral intertrochanteric region of the thigh. The incision must be sufficiently long to avoid traumatizing the soft tissues while exposing the intertrochanteric area. Using a sharp osteotome, the femur is osteotomized in a hinge-like manner, and the limb is extended to 170°. In cases of anatomical shortening, the limb is abducted sufficiently to compensate for the discrepancy via pelvic tilt.

The bone should be transected with care, as it is often sclerotic and brittle. In the event of adductor Muscle contracture that impedes hip abduction, tenotomy of the $m. ext{ adductor longus$ from the pelvic bone is performed. Following repositioning, the bone fragments are securely fixed with a metal plate or percutaneous Kirschner wires. After wound closure, a hip spica cast is applied, extending down the thigh of the healthy leg.

If a metal plate is used, the plaster cast can be removed after 4–5 weeks, allowing the patient to walk on crutches while mobilizing the knee joint. When fixation is achieved with wires, they are removed in 3–4 weeks, the cast on the healthy thigh is removed after 6–8 weeks, and the main cast is taken off once bony union of the fragments is achieved. Prolonged immobilization in a plaster cast leads to flexion-extension contracture of the knee joint and muscle hypotrophy of the limb, necessitating comprehensive rehabilitation therapy.

If anatomical limb shortening is present, the femur is lengthened using an Ilizarov distraction apparatus.