PDF | Although the prevalence of tuberculosis reduces, it still belongs to the most important infectious diseases worldwide even in industrial. Tuberculosis of the hip joint region in children. MAF MohideenI; MN RasoolII. I MBChB(Medunsa). Registrar. Nelson Mandela School of Medicine, University of . In particular, trochanteric bursitis is an extremely rare manifestation of osteoarticular tuberculosis. We describe a case of tuberculous coxitis.
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Tuberculosis of the hip joint region in children. To describe the clinical and radiological manifestations of tuberculosis of the hip joint and the resemblance to common osteoarticular lesions in children. Thirty-six children 1 to 12 years were reviewed retrospectively between and Clinical, laboratory and radiological features were assessed. The hips were classified and the outcome was graded as described by Shanmugasundaram.
Common clinical features were a limp, flexion, adduction and internal rotation contractures. Common radiological features were osteopaenia coxitiss cystic lesions in the neck and acetabulum. Permeative lesions, focal erosions, pathological fractures and sequestra were less common. Seven children had extra-articular lesions. Of doxitis 29 with osteoarticular involvement, six had purely synovial involvement. Osteoarticular lesions mimicked benign bone and joint conditions.
Other complications included avascular necrosis, coxa vara, coxa magna, growth arrest and flexion-adduction contractures. Tuberculosis of the hip can mimic various benign conditions.
Biopsy from a bony lesion is important. The initial radiological appearance predicts the outcome, especially in the ‘normal’ type of hip. Tuberculosis remains a major cause of skeletal infection in developing countries. Inalthough there were coxitix estimated 8. In the developed world an increase in the number of rb has been reported. This may be attributed to AIDS acquired immune-deficiency syndromeimmigration and intravenous drug abuse. Most of coxitix literature on tuberculosis of the hip in children is over 40 years old.
[Coxitis due to multidrug resistant Mycobacterium tuberculosis in a HIV negative patient].
Treatment was by prolonged traction and spica cast. Many surgeons used radical surgery and arthrodesis to control the disease. Osteoarticular manifestations may be intra-articular cocitis extra-articular. The aims of this study are to report the clinical and radiological patterns of tuberculosis of the hip joint region in children; highlight coxitix resemblance to various osteoarticular lesions; and correlate the radiological appearance with the outcome of treatment.
Thirty-six children were retrospectively reviewed between and at a local hospital. The ages ranged between 1 and 12 average 6 years. There were 21 boys and 15 girls.
All the osteoarticular lesions were histologically confirmed for tuberculosis. Clinical and radiological data were collected from case records. Haematological tests done for all patients included a full blood count, erythrocyte sedimentation rate and liver function tests. Radiological tests done included routine hip Coditis, chest X-ray and a bone scan. The Mantoux test was done routinely. Five children had computerised coditis scans to define the bone lesions within the hip.
Shanmugasundaram’s classification of tuberculosis of the hip joint was used to classify the different radiological patterns of tuberculosis of the hip into seven types 13 Figure 1. All patients coxtiis an open biopsy. Debridement, limited synovectomy and curettage of the osseous cavities and defects were performed when bone lesions were present. Antituberculosis treatment was used for a year. This consisted of isoniazide, rifampicin, pyrazinamide and pyridoxine. Post-operatively the hips were immobilised in a spica cast and physiotherapy was commenced after 3 to 4 weeks.
Hospital stay ranged between 3 and 8 weeks. Pain around the hip region and a limp were the main clinical features in all children. Three children had discharging sinuses and five had a fluctuant abscess.
One child presented with a pathological fracture of the proximal femur. The albumen was low in eight patients.
Four patients were known to be infected coxtis HIV and were on antiretrovirals for which they were being followed up by the coditis. The Mantoux test was negative in six children. All patients had histological features consistent with tuberculosis granulation, caseous necrosis and giant cells.
Localised osteopaenia was a common radiological finding. Twenty-six patients had cystic lesions which were either round or oval in shape in the head, neck or acetabulum.
Other lesions seen included the infiltrative permeativefusiform, punched-out erosions and pathologic fractures. In five patients the growth plate was traversed and four had a sequestrum Table I. Seven children had extra-capsular tuberculosis and 29 were intra-articular within the joint capsule in type.
Extra-articular osseous involvement was seen in the proximal femur, greater and lesser trochanter, ilium, ischium and body of the pubis Table II. Intra-articular infection involved the synovium, acetabulum, epiphysis, metaphysis or the epi-metaphyseal area Table II. Ocxitis the Shanmugasundaram classification there were eight ‘normal hips’ Figures 234 and 5seven dislocating Figure 6clxitis travelling acetabulum Figure 7two Perthes’, five protrusio acetabuli, two atrophic and three mortar-and-pestle types Figure 8 Table III.
Six hips required extension-abduction-derotation osteotomies for residual flexion adduction deformities.
Tuberculosis of hip: A current concept review
The pathological fracture healed with immobilisation by six weeks in a spica cast. Tuberculosis of the hip joint in children has a less destructive presentation than was seen in the past. The lesions coxifis present in a synovial or osseous form. The osseous lesions maybe intra-articular, within the joint capsule or extracapsular extra-articular.
The infection can progress through various stages with initial synovitis, effusion and rarefaction, to advanced arthritis cocitis complete destruction. Various radiological appearances are seen, i.
Phemister, in a detailed pathological study, found that primary bone involvement in children was usually metaphyseal due to embolism and infarction in metaphyseal end arteries.
The osseous lesions in this study were mainly metaphyseal appearing as cystic, permeative and focal erosions in the cancellous portions of the femoral head, neck and acetabulum.
Shanmugasundaram proposed a coxotis classification for tuberculosis of the hip joint. He described seven morphological types Figure I based on the destructive pattern for all ages. In the ‘normal’ type, the disease mainly involved the synovium. There may be cysts or cavities in the femoral head, neck or acetabulum, with no gross destruction of the subchondral bone and the joint space remains normal. Eight ‘normal hips’ with a good outcome were seen in this study. In the ‘travelling acetabulum’ type, the lesion is in the roof.
There is narrowing of the joint space, with progressive upward displacement of the femoral head. These are usually associated with a poor prognosis. Two cases were seen in this study with a fair outcome. In the ‘dislocating’ type, the head dislocates posteriorly, or subluxes due th laxity of ligaments fb capsular distension. The coxitid is poor. Seven cases were seen in this study, with poor results in three. Subluxed hips did well following reduction. In the Perthes’ type, the epiphysis is fragmented, dense and flattened.
The femoral neck is widened. It resembles Perthes’ disease and is probably coxihis to embolic episodes. Fibrous ankylosis was seen in two cases in this study.
In the ‘protrusio-acetabuli’ type, the lesion is mainly in the floor of the acetabulum. With progression, medial displacement of the floor occurs with pressure of the femoral head. The os innominatum gets thinned out in the acetabulum. The prognosis was reported to be good in children. We saw five cases in which the prognosis was fair.
[Coxitis due to multidrug resistant Mycobacterium tuberculosis in a HIV negative patient].
Articular cartilage was denuded at surgical exploration. The ‘atrophic’ hip is characterised by marked narrowing of the joint space. The differentiation from rheumatoid arthritis and idiopathic chondrolysis is difficult. It has a poor prognosis. Two children with poor results were seen in this study; they developed fibrous ankylosis. In the ‘mortar-and-pestle’ type, the head of the femur becomes ground down progressively, resembling a pestle within a mortar. Patients still retain a good range of movement.
We saw three cases with a fair result. The majority had a fair or poor result. This is due to late presentation with established radiological changes.
These hips were mainly of the poor prognostic types, with erosion of the head or acetabulum, dislocation or joint narrowing. The atrophic type had marked joint line narrowing resembling idiopathic chondrolysis. The clinical features were mainly flexion, adduction and internal rotation contractures with subsequent shortening.