Tuberculosis of the Hip
The hip is the second most common site for skeletal tuberculosis (after the spine). It is usually secondary to a primary focus in the lungs or lymph nodes and spreads via the bloodstream (hematogenous).
[Image of TB Hip Xray Deformity]1. Stages of TB Hip (Shanmugasundaram)
- Stage I (Synovitis): Effusion and soft tissue swelling. The hip is held in Flexion, Abduction, and External Rotation (Position of maximum capacity) to relieve pressure. Prognosis: Excellent (Normal hip possible).
- Stage II (Early Arthritis): Articular cartilage destruction. The "Wandering Acetabulum" may begin. Deformity shifts to Flexion, Adduction, and Internal Rotation.
- Stage III (Advanced Arthritis): Bone destruction, pathological dislocation, or wandering acetabulum.
- Stage IV (Advanced Dislocation/Ankylosis): Fibrous or bony fusion in a deformed position.
2. Clinical Features
- Night Cries: Child wakes up crying because muscle spasm relaxes during sleep, allowing inflamed bone surfaces to rub.
- Limp: Antalgic initially, later due to deformity/shortening.
- Muscle Wasting: Rapid atrophy of thigh and gluteal muscles.
3. Management
- Chemotherapy: Anti-Tubercular Therapy (ATT) is the cornerstone.
- Traction: To relieve spasm, prevent deformity, and maintain joint space.
- Surgery:
- Debridement: In early stages unresponsive to drugs.
- Girdlestone Excision Arthroplasty: Removal of femoral head/neck for severe infection/pain (creates a flail but painless hip).
- Arthrodesis (Fusion): For a stable, painless hip in young laborers.
- Total Hip Replacement (THR): Controversial; only done years after infection is quiescent.
25 Practice MCQs
Q1. The most common initial deformity in Stage I TB Hip is:
Answer: A). This increases joint volume to accommodate fluid.
Q2. In Stage II/III, the deformity typically changes to:
Answer: B). Due to muscle spasm and destruction of the joint.
Q3. "Night Cries" occur because:
Answer: A). A hallmark symptom in children.
Q4. "Wandering Acetabulum" refers to:
Answer: A). The femoral head erodes the roof, "wandering" upwards.
Q5. Girdlestone Arthroplasty involves:
Answer: A). Results in a mobile but unstable (short) hip. Used for severe infection.
Q6. The earliest radiographic sign of TB hip is:
Answer: A). Followed by haziness of joint margins.
Q7. "Babcock's Triangle" is a site for:
Answer: A). Common initial focus of infection.
Q8. The primary aim of traction in active TB is to:
Answer: A). Also separates joint surfaces to minimize destruction.
Q9. True shortening in TB hip is due to:
Answer: A). Destruction causes actual bone loss.
Q10. Apparent shortening is caused by:
Answer: A). The pelvis tilts up on the affected side to compensate.
Q11. Perthes-Junger disease is:
Answer: A). Isolated bursitis/osteomyelitis of the trochanter.
Q12. Fibrous Ankylosis is common in:
Answer: A). Pyogenic usually leads to Bony Ankylosis; TB leads to Fibrous (which is painful/unstable).
Q13. Which gait is seen in a fused hip (Arthrodesis)?
Answer: A). Requires increased lumbar and knee motion to compensate.
Q14. Otto Pelvis (Protrusio Acetabuli) involves:
Answer: A). Can occur in TB if the acetabular floor is destroyed.
Q15. Is Total Hip Replacement (THR) contraindicated in active TB?
Answer: A). Generally delayed until infection is quiescent for years.
Q16. Thomas Test is used to detect:
Answer: A). Common in late TB hip.
Q17. Cold abscess from the hip may point:
Answer: A). Following lines of least resistance.
Q18. "Kissing Sequestra" are seen in:
Answer: A). Dead bone on opposing surfaces.
Q19. Adductor Tenotomy may be needed to:
Answer: A). Adductor spasm is strong in TB hip.
Q20. Synovectomy is indicated in:
Answer: A). To save the cartilage.
Q21. Ideal position for Hip Arthrodesis (Fusion) is:
Answer: A). Allows sitting and walking.
Q22. Can TB Hip present as knee pain?
Answer: A). Always check hip in knee pain cases.
Q23. Pathological dislocation is most likely in:
Answer: A). Posterior superior dislocation is common.
Q24. "Phemister Triad" of TB Arthritis includes:
Answer: A). Classic triad.
Q25. Which hip movement is lost LAST in TB Hip?
Answer: A). Abduction and Rotation are lost first (the "Look" phase), Flexion persists longest.
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